Information Collection

Dialysis Component

IC 243719 under ICR 202205-0920-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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
0920-1317 / Form 5 COVID–19 Module - Dialysis Outpatient Facility 09102021_Dialysis COVID 19 Reporting Form Additional Dose 10.0 Release_FINAL.docx	Form and Instruction
0920-1317 / Form 5 COVID–19 Module - Dialysis Outpatient Facility 09102021_Dialysis COVID 19 Reporting Form Additional Dose 10.0 Release_FINAL.docx	Form and Instruction
0920-1317 / Form 5 COVID–19 Module - Dialysis Outpatient Facility 25MAY2022 Dialysis COVID 19 Reporting Form May 2022_FINAL.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
09102021_Dialysis Module TOIs_REVISED.docx Instructions for Dialysis Outpatient Facility COVID-19 Module 20SEP2021	IC Document
09102021_Dialysis Module TOIs_REVISED.docx Instructions for Dialysis Outpatient Facility COVID-19 Module 20SEP2021	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Dialysis Component

Agency IC Tracking Number:

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
Form and Instruction	0920-1317 / Form 57.510	COVIDâ19 Module - Dialysis Outpatient Facility	09102021_Dialysis COVID 19 Reporting Form Additional Dose 10.0 Release_FINAL.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317 / Form 57.510	COVIDâ19 Module - Dialysis Outpatient Facility 25MAY2022	Dialysis COVID 19 Reporting Form May 2022_FINAL.docx	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,700

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	800,800	0	800,800
Annual IC Time Burden (Hours)	200,200	-133,467	333,667
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
Instructions for Dialysis Outpatient Facility COVID-19 Module 20SEP2021	09102021_Dialysis Module TOIs_REVISED.docx	09/20/2021

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