OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Undetermined Cause of Cardiac Arrest during Hemodialysis — Connecticut 2015-2016

OMB 0920-1095 · HHS/CDC.

OMB 0920-1095

Latest Forms, Documents, and Supporting Material

Document Name
Dialysis–related Cardiac Arrest Data Collection Tool for data received through Case Finding Form and Instruction
Questionnaire for Staff at the Clinic at the time of the Event Form and Instruction
Questionnaire for Other Patients who were receiving Dialysis at the same time of the Event Form and Instruction
Questionnaire for Patients who Suffered from Cardiac Arrest but Survived Form and Instruction
Emergency SSB Cardiac Arrest in CT.docx Supporting Statement B
Emergency SSA Cardiac Arrest in CT.docx Supporting Statement A
Att 7 - Chart Abstraction Tool.docx Supplementary Document
Att 8 - IRB Determination.pdf Supplementary Document
Cluster cardiac arrest emergency memo.pdf Supplementary Document
Att 2 - Cardiac arrest in CT 60 day FRN.docx Supplementary Document
Att 1 - Authorizing Legislation T42 Section 241.doc Supplementary Document
Dialysis–related Cardiac Arrest Data Collection Tool for data received through Case Finding Form and Instruction
Questionnaire for Staff at the Clinic at the time of the Event Form and Instruction
Questionnaire for Other Patients who were receiving Dialysis at the same time of the Event Form and Instruction
Questionnaire for Patients who Suffered from Cardiac Arrest but Survived Form and Instruction

All Historical Document Collections

201601-0920-014

Approved without change

New collection (Request for a new OMB Control Number)

2016-01-27