Information Collection

End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60

IC 8003 under ICR 201603-0938-007 · OMB 0938-0360.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0360 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-3427 End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60 Form and Instruction
CMS-3427 ESRD Application and Survey and Certification Report CMS-3427-Reinstatement-for OMB-PRA(508).pdf Form and Instruction
Revised CMS-3427-Changes-Table(508).pdf Crosswalk Document IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-3427	ESRD Application and Survey and Certification Report	CMS-3427-Reinstatement-for OMB-PRA(508).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,046	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,046	2,046
Annual IC Time Burden (Hours)	682	682
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk Document	Revised CMS-3427-Changes-Table(508).pdf	03/07/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.