57.500 Outpatient Dialysis Center Practices Survey

The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CDC 57.500 57.500 Outpatient Dialysis Center Practices Survey Form
CDC 57.500 Outpatient Dialysis Center Practices Survey 57.500_OutpatientDialysisSurv_BLANK.docx Form
17. Outpatient Procedure Component.pdf Att. G17_Outpatient Procedure Component IC Document

Information Collection (IC) Details

IC Title:	57.500 Outpatient Dialysis Center Practices Survey	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC 57.500	Outpatient Dialysis Center Practices Survey	57.500_OutpatientDialysisSurv_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: 7,100	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: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,100	7,100
Annual IC Time Burden (Hours)	15,975	15,975
Annual IC Cost Burden (Dollars)	577,230	577,230

Documents for IC

Title	Document	Date Uploaded
Att. G17_Outpatient Procedure Component	17. Outpatient Procedure Component.pdf	09/25/2018

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