National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)

National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) (CMS-10639)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1340 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10639 National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) Form and Instruction
CMS-10639 Request Letter to Facilities Records CMS_10639_NHSN Request Letter to Facilities_Records_Template.docx Form and Instruction
CMS-10639 Request Letter to Facilities Records CMS_10639_NHSN Request Letter to Facilities_Records_Template.docx Form and Instruction
CMS-10639 Request Letter to Facilities - List CMS-10639_NHSN Request Letter to Facilities_List_Template.docx Form and Instruction
CMS-10639 Request Letter to Facilities - List CMS-10639_NHSN Request Letter to Facilities_List_Template.docx Form and Instruction
CMS_10639_Message Introducing Contractor to All Facilities_template.docx Contractor Letter IC Document
CMS_10639_Message Introducing Contractor to All Facilities_template.docx Contractor Letter IC Document

Information Collection (IC) Details

IC Title:	National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 1395R (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10639	Request Letter to Facilities Records	CMS_10639_NHSN Request Letter to Facilities_Records_Template.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10639	Request Letter to Facilities - List	CMS-10639_NHSN Request Letter to Facilities_List_Template.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: ESRD Program Management and Medical Information System (PMMIS)	FR Citation: 74 FR 30606

Number of Respondents: 300	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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	1,500	1,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Contractor Letter	CMS_10639_Message Introducing Contractor to All Facilities_template.docx	01/07/2020

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