Information Collection

57.502 Dialysis Event

IC 183547 under ICR 201808-0920-011 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.502 57.502 Dialysis Event	Form
CDC 57.502 Dialysis Event 57.502_DE_Form_BLANK.docx	Form
9. Dialysis Event.pdf Att G9.Dialysis Event	IC Document

IC Title:

57.502 Dialysis Event

Agency IC Tracking Number:

0920-0666

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC 57.502	Dialysis Event	57.502_DE_Form_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	420,000	420,000
Annual IC Time Burden (Hours)	175,000	175,000
Annual IC Cost Burden (Dollars)	5,678,820	5,678,820

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G9.Dialysis Event	9. Dialysis Event.pdf	09/24/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.