Information Collection

End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations -- 42 CFR 405.2135-.2171, 488.60

IC 8001 under ICR 199703-0938-004 · OMB 0938-0360.

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IC Title:

End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations -- 42 CFR 405.2135-.2171, 488.60

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	HCFA-3427				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,640

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,056	1,056
Annual IC Time Burden (Hours)	2,376	2,376
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Title	Document	Date Uploaded

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