End Stage Renal Disease Medical Information System ESRD Facility Survey and Supporting Regulations in 42 CFR 405.2133

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0447 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-2744 End Stage Renal Disease Medical Information System ESRD Facility Survey and Supporting Regulations in 42 CFR 405.2133 Instruction
CMS-2744 ESRD Facility Survey Instructions for Completion CMS-2744.Current facility survey instructions.pdf Instruction
CMS-2744B End Stage Renal Disease Medical Information System ESRD CMS-2744B.pdf Form
CMS-2744A End Stage Renal Disease Medical Information System ESRD CMS-2744A.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	End Stage Renal Disease Medical Information System ESRD Facility Survey and Supporting Regulations in 42 CFR 405.2133	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 405.2133 45 CFR 5.5b 20 CFR 401.. 20 CFR 422.Subpart E

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	CMS-2744	ESRD Facility Survey Instructions for Completion	CMS-2744.Current facility survey instructions.pdf	Yes	No	Printable Only
Form	CMS-2744B	End Stage Renal Disease Medical Information System ESRD Facility Survey (Transplant Centers Only)	CMS-2744B.pdf	Yes	No	Printable Only
Form	CMS-2744A	End Stage Renal Disease Medical Information System ESRD Facility Survey (Dialysis Units Only)	CMS-2744A.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,800	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,800	440	4,360
Annual IC Time Burden (Hours)	38,400	3,520	34,880
Annual IC Cost Burden (Dollars)	0	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.