Information Collection

J.10 Nursing Home Dialysis Survey

IC 268792 under ICR 202406-0938-008 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10842 J.10 Nursing Home Dialysis Survey	Form and Instruction
CMS-10842 End Stage Renal Disease (ESRD) Annual Home Dialysis with CMS- 10842i508-Nursing Home Dialysis Survey Tool- clean.pdf	Form and Instruction
CMS-10842 End Stage Renal Disease (ESRD) Annual Home Dialysis with CMS- 10842i508-Nursing Home Dialysis Survey Tool- clean.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	CMS-10842	End Stage Renal Disease (ESRD) Annual Home Dialysis within Nursing Home Survey Form	CMS- 10842i508-Nursing Home Dialysis Survey Tool- clean.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,726

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,726	7,726
Annual IC Time Burden (Hours)	5,795	5,795
Annual IC Cost Burden (Dollars)	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.