Information Collection

57.510 COVID–19 Module Dialysis Outpatient Facility_Manual

IC 243719 under ICR 202602-0920-005 · OMB 0920-1317.

Documents and Forms

Document Name Document Type
Form 57.510 COVID–19 Module - Dialysis Outpatient Facility 57.510 COVID–19 Module Dialysis Outpatient Facility_Manual Form and Instruction
57.510 COVID–19 Module - Dialysis Outpatient Facility Dialysis COVID 19 Reporting Form May 2022_FINAL.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.510 COVIDâ19 Module Dialysis Outpatient Facility_Manual	Agency IC Tracking Number:	0920-1317

Is this a Common Form? No		IC Status: Unchanged

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	57.510	COVIDâ19 Module - Dialysis Outpatient Facility	Dialysis COVID 19 Reporting Form May 2022_FINAL.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	2,000	2,000
Annual IC Cost Burden (Dollars)	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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