Information Collection

57.500 Outpatient Dialysis Center Practices Survey

IC 183544 under ICR 202112-0920-014 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.500 Outpatient 57.500 Outpatient Dialysis Center Practices Survey	Form
57.500 Outpatient 57.500_DialSurv.2021 57.500_DialSurv.2021.pdf	Form
57.500 57.500 Home Survey 2022_Final 57.500_Home_Survey_2022_Final[1].docx	Form and Instruction
17. Outpatient Procedure Component.pdf Att. G17_Outpatient Procedure Component	IC Document
17. Outpatient Procedure Component.pdf Att. G17_Outpatient Procedure Component	IC Document

IC Title:

57.500 Outpatient Dialysis Center Practices Survey

Agency IC Tracking Number:

0920-0666

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	57.500	57.500 Home Survey 2022_Final	57.500_Home_Survey_2022_Final[1].docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,200

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	Previously Approved
Annual Number of Responses for this IC	7,200	7,200
Annual IC Time Burden (Hours)	1,440	1,440
Annual IC Cost Burden (Dollars)	585,360	585,360

Documents for IC

table that charts IC Documents
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.