Information Collection

57.500 Outpatient Dialysis Center Practices Survey

IC 183544 under ICR 202410-0920-013 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.500 57.500 Outpatient Dialysis Center Practices Survey	Form and Instruction
57.500 Home Dialysis Center Practices Survey 57.500 Outpatient Dialysis Practices Survey_2025-Clean Version.docx	Form and Instruction
57.500 Home Dialysis Center Practices Survey 57.500 Outpatient Dialysis Practices Survey_2025-Clean Version.docx	Form and Instruction

IC Title:

57.500 Outpatient Dialysis Center Practices Survey

Agency IC Tracking Number:

0920-0666

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	57.500	Home Dialysis Center Practices Survey	57.500 Outpatient Dialysis Practices Survey_2025-Clean Version.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,900

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	6,900	-500	7,400
Annual IC Time Burden (Hours)	17,250	15,770	1,480
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.