Information Collection

57.510 COVID–19 Module Dialysis Outpatient Facility_Manual

IC 243719 under ICR 202410-0920-012 · OMB 0920-1317.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1317 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.510 57.510 COVID–19 Module Dialysis Outpatient Facility_Manual	Form and Instruction
57.510 COVID–19 Module - Dialysis Outpatient Facility Dialysis COVID 19 Reporting Form May 2022_FINAL.docx	Form and Instruction
57.510 COVID–19 Module - Dialysis Outpatient Facility Dialysis COVID 19 Reporting Form May 2022_FINAL.docx	Form and Instruction

IC Title:

57.510 COVIDâ19 Module Dialysis Outpatient Facility_Manual

Agency IC Tracking Number:

0920-1317

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	57.510	COVIDâ19 Module - Dialysis Outpatient Facility	Dialysis COVID 19 Reporting Form May 2022_FINAL.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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	Previously Approved
Annual Number of Responses for this IC	6,000	-794,800	800,800
Annual IC Time Burden (Hours)	2,000	-331,667	333,667
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.