End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E

Forms and Documents

Document Name	Status
Form CMS-2746 End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E Form and Instruction	Modified
CMS-2746.Supporting Statement Part A-10-12-10.doc Supporting Statement A	2010-10-12

IC Document Collections

IC ID	Document Title	Status
8067	End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0448	ICR Reference No: 201007-0938-015
Status: Historical Active	Previous ICR Reference No: 200609-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/18/2010
	Date Received in OIRA: 07/28/2010
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved. This approval only extends to the instrument contained in this request. Should the Vital Information System to Improve Outcomes in Nephrology (VISION) obtain this information through anything other than this form, the agency should submit a request for approval for that instrument. They may make this request through a non-substantive revision to this collection. As the agency develops the CROWNWeb application, they are encouraged to consult with OMB to ensure that they obtain approval for the information collections contained in this application as soon as appropriate. Note: Because HHS did not request approval of submission of this form via

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	36 Months From Approved
Responses	82,768	0	0
Time Burden (Hours)	41,384	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The ESRD Death Notification is to be completed upon the death of ESRD patients. Its primary purpose is to collect facts and cause of death. Reports of deaths are used to show cause of death and demographic characteristics of these patients.

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Authorizing Statute(s): PL: Pub.L. 95 - 292 226 Name of Law: The ESRD Amendments of 1978
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 4826	01/29/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 34742	06/18/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E	CMS-2746	ESRD Death Notification

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	82,768	0	0	0	7,264	75,504
Annual Time Burden (Hours)	41,384	0	0	0	3,632	37,752
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $28,595

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/28/2010

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