Information Collection

: End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network

IC 217583 under ICR 202607-0938-011 · OMB 0938-1289.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10569 Letter to Facilities - data collection : End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network	Form and Instruction
Form CMS-10569 EQRS Global App : End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network	Form and Instruction
CMS_10569- Message Introducing Contractor to All Facilities_template.docx	Instruction
CMS-10569 Letter to Facilities - data collection CMS_10569_CPM Request Letter to Facilities_template.docx	Form and Instruction
CMS-10569 EQRS Global App ESRD QIP EQRS System Screenshot Files 2026-07-21 (Task 2).pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

: End-Stage Renal Disease Quality Incentive Program: Data Collection for Quality Measures Using the Consolidated Renal Operations in a Web-Enabled Network

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10569	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10569	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

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

FR Citation: 74 FR 30606

Number of Respondents: 7,582

Number of Respondents for Small Entity: 958

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	513,475	0	513,475
Annual IC Time Burden (Hours)	777,594	-85,579	863,173
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.

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