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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 224551 under ICR 202007-0938-003 · OMB 0938-1340.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)
 
No Modified
 
Mandatory
 
42 CFR 1395R  (To search for a specific CFR, visit the Code of Federal Regulations.)

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

Health Health Care Services

 

300 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 6,000 0 -6,000 0 0 12,000
Annual IC Time Burden (Hours) 1,500 0 -1,500 0 0 3,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.