Information Collection

Dialysis Component

IC 243719 under ICR 202102-0920-015 · OMB 0920-1317.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1317 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-20LW Dialysis Component Form and Instruction
0920-20LW Dialysis Component covid19 dialysis outpatient module_v6_08112020 (002)kab final.docx Form and Instruction
0920-1317 COVID-19 Module Dialysis Outpatient Facility Dialysis COVID 19 Reporting Form Clean.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Dialysis Component	Agency IC Tracking Number:	0920-20LW

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	0920-20LW	Dialysis Component	covid19 dialysis outpatient module_v6_08112020 (002)kab final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1317	COVID-19 Module Dialysis Outpatient Facility	Dialysis COVID 19 Reporting Form Clean.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: 4,900	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	509,600	509,600
Annual IC Time Burden (Hours)	169,867	169,867
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.