National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)

National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) (CMS-10639)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1340 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10639 National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) Form and Instruction
CMS-10639 Request Letter to Facilities Records CMS_10639_NHSN Request Letter to Facilities_Records_Template.docx Form and Instruction
CMS-10639 Request Letter to Facilities - List CMS-10639_NHSN Request Letter to Facilities_List_Template.docx Form and Instruction
CMS_10639_Message Introducing Contractor to All Facilities_template.docx Contractor Letter IC Document

Information Collection (IC) Details

IC Title:	National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 1395R (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10639	Request Letter to Facilities Records	CMS_10639_NHSN Request Letter to Facilities_Records_Template.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10639	Request Letter to Facilities - List	CMS-10639_NHSN Request Letter to Facilities_List_Template.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,000	6,000	6,000
Annual IC Time Burden (Hours)	3,000	1,500	1,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Contractor Letter	CMS_10639_Message Introducing Contractor to All Facilities_template.docx	01/07/2020

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