Information Collection

End-Stage Renal Disease (ESRD) Network Business Proposal Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112

IC 8240 under ICR 200612-0938-008 · OMB 0938-0658.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-684 A ESRD Network Business Proposal Forms End-Stage Renal Disease (ESRD) Network Business Proposal Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	Form
Form CMS-684 A-I Annual Management Plan End-Stage Renal Disease (ESRD) Network Business Proposal Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	Form
FINALJ-7instructions_060208.doc	Instruction
CMS-684 A ESRD Network Business Proposal Forms FINALESRDBPformsJ-7a_01262005(2).xls	Form
CMS-684 A-I Annual Management Plan FINALj-7bmanagementplan.xls	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.2110 42 CFR 405.2112

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-684 A	Yes	Yes	Fillable Fileable
Form	CMS-684 A-I	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	1,080	1,080
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].