Information Collection

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

IC 224551 under ICR 202607-0938-010 · OMB 0938-1340.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10639 Request Letter to Facilities Records National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)	Form and Instruction
Form CMS-10639 Request Letter to Facilities - List National Healthcare Safety Network (NHSN) Data Validation Study for the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)	Form and Instruction
CMS-10639 Request Letter to Facilities Records CMS_10639_NHSN R .docx	Form and Instruction
CMS-10639 Request Letter to Facilities - List CMS-10639_NHSN Request Letter to Facilities_List_Template.docx	Form and Instruction
CMS_10639_Message Introducing Contractor to All Facilities_template.docx Contractor Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 1395R (To search for a specific CFR, visit the Code of Federal Regulations.)

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	CMS-10639				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10639				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: ESRD Program Management and Medical Information System (PMMIS)

FR Citation: 74 FR 30606

Number of Respondents: 300

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: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	1,500	1,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Contractor Letter		01/07/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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