Information Collection

: End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network

IC 217583 under ICR 202401-0938-005 · OMB 0938-1289.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1289 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10569 : End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network	Form and Instruction
Form CMS-10569 : End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network	Form and Instruction
CMS_10569- Message Introducing Contractor to All Facilities_template.docx	Instruction
CMS_10569- Message Introducing Contractor to All Facilities_template.docx	Instruction
CMS-10569 Letter to Facilities - data collection CMS_10569_CPM Request Letter to Facilities_template.docx	Form and Instruction
CMS-10569 Letter to Facilities - data collection CMS_10569_CPM Request Letter to Facilities_template.docx	Form and Instruction
CMS-10569 EQRS Global App CMS-10569 screenshots 3-30-2020.docx	Form and Instruction
CMS-10569 EQRS Global App CMS-10569 screenshots 3-30-2020.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

: End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10569	Letter to Facilities - data collection	CMS_10569_CPM Request Letter to Facilities_template.docx	Yes	Yes	Fillable Fileable
Instruction			CMS_10569- Message Introducing Contractor to All Facilities_template.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10569	EQRS Global App	CMS-10569 screenshots 3-30-2020.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: ESRD Program Management and Medical Information System (PMMIS) published

FR Citation: 74 FR 30606

Number of Respondents: 7,833

Number of Respondents for Small Entity: 958

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	507,837	-25,094	532,931
Annual IC Time Burden (Hours)	1,848,212	-1,424,232	3,272,444
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.