Information Collection

Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form

IC 244455 under ICR 202011-0920-005 · OMB 0920-1306.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Dialysis Facility Infection Preventionists - Dialysis COVID-19 Outpatient Form	Form
Dialysis COVID-19 Outpatient Form COVID 19 dialysis outpatient module form CLEAN.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	NA	Dialysis COVID-19 Outpatient Form	COVID 19 dialysis outpatient module form CLEAN.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,900

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
Annual Number of Responses for this IC	509,600	509,600
Annual IC Time Burden (Hours)	127,400	127,400
Annual IC Cost Burden (Dollars)	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.