End Stage Renal Disease (ESRD) System Access Request Form

Forms and Documents

Document	Type	Status	Availability
Form CMS-10484 ESRD System Access Request Form	Form and Instruction	New	Available
Crosswalk.docx	Supplementary Document	Uploaded 2013-10-31	Available
CMS-10484 Supporting Statement for ESRD System Access Request Form.doc	Supporting Statement A	Uploaded 2013-10-31	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
209155	ESRD System Access Request Form	Form and Instruction	New

ICR Details

OMB Control No: 0938-1234	ICR Reference No: 201310-0938-015
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 20816
Title: End Stage Renal Disease (ESRD) System Access Request Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/21/2014
	Date Received in OIRA: 10/31/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved
Responses	27,000	0	0
Time Burden (Hours)	6,750	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: he sole purpose the ESRD System Access Request Form is to identify the individual's data access rights once within the ESRD system. This function/data collection is currently being accomplished under "Part B" of the QualityNet Identity Management System Account Form (CMS-10267; OMB Control# 0938-1050). Once the ESRD System Access Form is approved, the QualityNet Identity Management System (QIMS) Account Form will be revised to remove Part B from the QIMS data collection.

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Authorizing Statute(s): None

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 38986	06/28/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 61364	10/03/2013
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
ESRD System Access Request Form	CMS-10484	ESRD System Access Request Form

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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	27,000	0	0	27,000	0	0
Annual Time Burden (Hours)	6,750	0	0	6,750	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This new ESRD Application Access Request Form was originally submitted as "Part B" of the QualityNet Identity Management System Account Form (CMS-10267; OMB Control# 0938-1050). Once this submission is approved, the QualityNet Identity Management System (QIMS) Account Form will be revised to remove Part B from QIMS collection. ESRD system accounts created using the current QIMS Account Form - Part B will not need to submit an ESRD Application Access Form for the creation of their account since that information was collected under Part B.

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Annual Cost to Federal Government: $10,000

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: 10/31/2013

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