Information Collection

Dialysis Component

IC 243719 under ICR 202105-0920-014 · OMB 0920-1317.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1317 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-20LW Dialysis Component	Form and Instruction
0920-20LW Dialysis Component covid19 dialysis outpatient module_v6_08112020 (002)kab final.docx	Form and Instruction
0920-20LW Dialysis Component covid19 dialysis outpatient module_v6_08112020 (002)kab final.docx	Form and Instruction
0920-1317 COVID-19 Module Dialysis Outpatient Facility Dialysis COVID 19 Reporting Form Clean.docx	Form and Instruction
0920-1317 COVID-19 Module Dialysis Outpatient Facility Dialysis COVID 19 Reporting Form Clean.docx	Form and Instruction
0920-1317 COVID-19 Module Dialysis Outpatient Facility Form 27MAY2 Dialysis COVID 19 Reporting Form Final 9.5.4 Release.docx	Form and Instruction
0920-1317 COVID-19 Module Dialysis Outpatient Facility Form 27MAY2 Dialysis COVID 19 Reporting Form Final 9.5.4 Release.docx	Form and Instruction
COVID Dialysis Module TOIs for Users 9.5.4 Release_Final.docx Instructions for Dialysis Outpatient Facility COVID-19 Module 27MAY2021	IC Document
COVID Dialysis Module TOIs for Users 9.5.4 Release_Final.docx Instructions for Dialysis Outpatient Facility COVID-19 Module 27MAY2021	IC Document

IC Title:

Dialysis Component

Agency IC Tracking Number:

0920-20LW

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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 and Instruction	0920-20LW	Dialysis Component	covid19 dialysis outpatient module_v6_08112020 (002)kab final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317	COVID-19 Module Dialysis Outpatient Facility	Dialysis COVID 19 Reporting Form Clean.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317	COVID-19 Module Dialysis Outpatient Facility Form 27MAY2021	Dialysis COVID 19 Reporting Form Final 9.5.4 Release.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: 7,900

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	Previously Approved
Annual Number of Responses for this IC	821,600	312,000	509,600
Annual IC Time Burden (Hours)	342,333	172,466	169,867
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Instructions for Dialysis Outpatient Facility COVID-19 Module 27MAY2021	COVID Dialysis Module TOIs for Users 9.5.4 Release_Final.docx	05/27/2021

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