Information Collection

57.510 COVID–19 Module Dialysis Outpatient Facility-CSV

IC 271955 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⚠️ Notice: This information collection may be referencing outdated material.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-CSV	Form and Instruction
57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-.csv 57.510 COVID 19 Module Dialysis Outpatient Facility.docx	Form and Instruction
57.510 57.510 COVID–19 Module Dialysis Outpatient Facility-.csv 57.510 COVID 19 Module Dialysis Outpatient Facility.docx	Form and Instruction

IC Title:

57.510 COVIDâ19 Module Dialysis Outpatient Facility-CSV

Agency IC Tracking Number:

0920-1317

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	57.510	57.510 COVIDâ19 Module Dialysis Outpatient Facility-.csv	57.510 COVID 19 Module Dialysis Outpatient Facility.docx	N/A	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
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	1,000	1,000
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.