End Stage Renal Disease Death Notification

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 Final Supporting Statement.doc Supporting Statement A	2013-10-21

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: 201310-0938-005
Status: Historical Active	Previous ICR Reference No: 201007-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No: 20701
Title: End Stage Renal Disease Death Notification
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/21/2014
	Date Received in OIRA: 10/25/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved	04/30/2014
Responses	75,000	0	82,768
Time Burden (Hours)	37,500	0	41,384
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:
	78 FR 41931	07/12/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 61846	10/04/2013
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	75,000	82,768	0	-7,768	0	0
Annual Time Burden (Hours)	37,500	41,384	0	-3,884	0	0
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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The changes to the total annual reporting or record keeping hour burden reflects increases in the cost of respondents, responses and corresponding deaths each year.

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Annual Cost to Federal Government: $0

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: 10/25/2013

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