Information Collection

57.504 Prevention Process Measures Monthly Monitoring for Dialysis

IC 208409 under ICR 201908-0920-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.504 57.504 Prevention Process Measures Monthly Monitoring for Dialysis	Form
CDC 57.504 Prevention Process Measures Monthly Monitoring for Dialy 57.504_DIALProcessMeasureSummary_BLANK.docx	Form
11. Dialysis Prevention Process Measures.pdf Att G11_Dialysis Prevention Process Measures	IC Document

IC Title:

57.504 Prevention Process Measures Monthly Monitoring for Dialysis

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 57.504	Prevention Process Measures Monthly Monitoring for Dialysis	57.504_DIALProcessMeasureSummary_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: 1,760

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	21,120	9,120	12,000
Annual IC Time Burden (Hours)	26,400	9,360	17,040
Annual IC Cost Burden (Dollars)	856,669	369,925	486,744

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G11_Dialysis Prevention Process Measures	11. Dialysis Prevention Process Measures.pdf	09/26/2018

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