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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Information Collection (IC) Details

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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:

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 %

	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

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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.