Information Collection

57.500 Outpatient Dialysis Center Practices Survey

IC 183544 under ICR 202603-0920-006 · OMB 0920-0666.

Documents and Forms

Document Name Document Type
Form 57.500 Home Dialysis Center Practices Survey 57.500 Outpatient Dialysis Center Practices Survey Form and Instruction
57.500 Home Dialysis Center Practices Survey 57.500 Outpatient Dialysis Practices Survey_2026_Clean_09292025.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

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_2026_Clean_09292025.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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,900	0	6,900
Annual IC Time Burden (Hours)	17,135	-115	17,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.

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