National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) (CMS-10639)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10639 Request Letter to Facilities - List	Form and Instruction	Unchanged	Available
Form CMS-10639 Request Letter to Facilities Records	Form and Instruction	Unchanged	Available
CMS-10639 Supporting Statement A NHSN CY 2027 (06-23-2026).docx	Supporting Statement A	Uploaded 2026-07-22	Available
CMS-10639 Supporting Statement B NHSN CY 2027 (06-23-2026)).docx	Supporting Statement B	Uploaded 2026-07-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
224551	National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)	Form and Instruction	Unchanged	Request Letter to Facilities - List
224551	National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)	Form and Instruction	Unchanged	Request Letter to Facilities Records

ICR Details

OMB Control No: 0938-1340	ICR Reference No: 202607-0938-010
Status: Received in OIRA	Previous ICR Reference No: 202601-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) (CMS-10639)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/22/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2029
Responses	6,000	6,000
Time Burden (Hours)	1,500	1,500
Cost Burden (Dollars)	0	0

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Abstract: For the PY 2028 validation, CMS is continuing to use its previously finalized policy to select 300 facilities to participate in an NHSN Dialysis Event validation by submitting a total of 20 patient records across any two quarters of data reported in CY 2026.

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Authorizing Statute(s): US Code: 42 USC 1395R Name of Law: End State Renal Disease
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV81	Proposed rulemaking	91 FR 38784	06/26/2026

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)	CMS-10639, CMS-10639	Request Letter to Facilities Records ,   Request Letter to Facilities - List

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	6,000	6,000	0	0	0	0
Annual Time Burden (Hours)	1,500	1,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $188,503

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/22/2026

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