Information Collection

: End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network

IC 217583 under ICR 201912-0938-005 · OMB 0938-1289.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1289 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10569 : End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network	Form and Instruction
Message Introducing Contractor to All Facilities_template.docx	Instruction
CMS-10569 Request Letter to Facilities_template CPM Request Letter to Facilities_template.docx	Form and Instruction
CMS-10569 Screenshots ESRD QIP Application Screenshots_Prod_20200116.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

: End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10569	Request Letter to Facilities_template	CPM Request Letter to Facilities_template.docx	Yes	Yes	Fillable Fileable
Instruction			Message Introducing Contractor to All Facilities_template.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10569	Screenshots	ESRD QIP Application Screenshots_Prod_20200116.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,386

Number of Respondents for Small Entity: 958

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	523,314	13,376	509,938
Annual IC Time Burden (Hours)	3,329,109	231,726	3,097,383
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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