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

Document Name Document 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)

IC Title:	End-stage Renal Disease (ESRD) Quality Incentive Program (QIP): Study of Quality and Patient Experience	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,945	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,945	1,945
Annual IC Time Burden (Hours)	604	604
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.