Information Collection

ESRD Beneficiary Selection and Supporting Regulations Contained in 42 CFR 414.330

IC 8010 under ICR 200712-0938-002 · OMB 0938-0372.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-382 ESRD Beneficiary Selection and Supporting Regulations Contained in 42 CFR 414.330	Form and Instruction
CMS-382 ESRD Beneficiary Selection CMS382.pdf	Form and Instruction

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 414.330

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 and Instruction	CMS-382	ESRD Beneficiary Selection	CMS382.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	7,400	7,400
Annual IC Time Burden (Hours)	617	617
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.