OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

End-stage Renal Disease (ESRD) Quality Incentive Program (QIP): Study of Quality and Patient Experience

IC 260048 under ICR 202305-0938-002 · OMB 0938-1450.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10823
End-stage Renal Disease (ESRD) Quality Incentive Program (QIP): Study of Quality and Patient Experience		 Form and Instruction
CMS-10823 Appendix A
CMS-10823 ESRD_QIP_M&E AppA- Patient Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix A
CMS-10823 ESRD_QIP_M&E AppA- Patient Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix B
CMS-10823 ESRD_QIP_M&E AppB - Facility Review Protocol.pdf 		Form and Instruction
CMS-10823 Appendix B
CMS-10823 ESRD_QIP_M&E AppB - Facility Review Protocol.pdf 		Form and Instruction
CMS-10823 Appendix C
CMS-10823 ESRD_QIP_M&E AppC- Dialysis Facility Social Worker Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix C
CMS-10823 ESRD_QIP_M&E AppC- Dialysis Facility Social Worker Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix D
CMS-10823 ESRD_QIP_M&E AppD - Nephrologist Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix D
CMS-10823 ESRD_QIP_M&E AppD - Nephrologist Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix E
CMS-10823 ESRD_QIP_M&E AppE - Transplant Center Administrator Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix E
CMS-10823 ESRD_QIP_M&E AppE - Transplant Center Administrator Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix F
CMS-10823 ESRD_QIP_M&E AppF - Dialysis Organization Corporate Representative.pdf 		Form and Instruction
CMS-10823 Appendix F
CMS-10823 ESRD_QIP_M&E AppF - Dialysis Organization Corporate Representative.pdf 		Form and Instruction
CMS-10823 Appendix G
CMS-10823 ESRD_QIP_M&E AppG - Patient Advocacy Organization Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix G
CMS-10823 ESRD_QIP_M&E AppG - Patient Advocacy Organization Interview Protocol.pdf 		Form and Instruction
CMS-10823 Appendix H
CMS-10823 ESRD_QIP_M&E AppH - Recruitment Materials.pdf 		Form and Instruction
CMS-10823 Appendix H
CMS-10823 ESRD_QIP_M&E AppH - Recruitment Materials.pdf 		Form and Instruction
CMS-10823 Appendix I
CMS-10823 ESRD_QIP_M&E AppI - Participant Screeners.pdf 		Form and Instruction
CMS-10823 Appendix I
CMS-10823 ESRD_QIP_M&E AppI - Participant Screeners.pdf 		Form and Instruction
CMS-10823 Appendix J
CMS-10823 ESRD_QIP_M&E AppJ - Informed Consent.pdf 		Form and Instruction
CMS-10823 Appendix J
CMS-10823 ESRD_QIP_M&E AppJ - Informed Consent.pdf 		Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 CMS-10823 Appendix A CMS-10823 ESRD_QIP_M&E AppA- Patient Interview Protocol.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10823 Appendix B CMS-10823 ESRD_QIP_M&E AppB - Facility Review Protocol.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10823 Appendix C CMS-10823 ESRD_QIP_M&E AppC- Dialysis Facility Social Worker Interview Protocol.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10823 Appendix D CMS-10823 ESRD_QIP_M&E AppD - Nephrologist Interview Protocol.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10823 Appendix E CMS-10823 ESRD_QIP_M&E AppE - Transplant Center Administrator Interview Protocol.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10823 Appendix F CMS-10823 ESRD_QIP_M&E AppF - Dialysis Organization Corporate Representative.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10823 Appendix G CMS-10823 ESRD_QIP_M&E AppG - Patient Advocacy Organization Interview Protocol.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10823 Appendix H CMS-10823 ESRD_QIP_M&E AppH - Recruitment Materials.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10823 Appendix I CMS-10823 ESRD_QIP_M&E AppI - Participant Screeners.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10823 Appendix J CMS-10823 ESRD_QIP_M&E AppJ - Informed Consent.pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved 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 1,945 0 1,945 0 0 0
Annual IC Time Burden (Hours) 604 0 604 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.