End Stage Renal Disease Medical Information System ESRD Facility Survey and Supporting Regulations in 42 CFR 405.2133

ESRD FACILITY SURVEY
(CMS-2744)
INSTRUCTIONS FOR COMPLETION
REPORTING RESPONSIBILITY
The ESRD Facility Survey is designed to capture only a limited amount of information
concerning each Federally approved renal facility’s operation. It is not intended to yield
information on the full range of ancillary services or activities, e.g., referrals, graft outcome, etc.
These concerns are more appropriately and validly addressed by the network in supplemental
requests or through other segments of the Program Management and Medical Information
System.
Every facility/center approved by Medicare to provide services to ESRD patients must furnish
the information requested in the ESRD Facility Survey (42 U.S.C. 426; 20 CFR 405, Section
2133). It is also the facility’s/center’s responsibility to provide patient and treatment counts to
their local ESRD Network upon termination of operations. Facilities certified as only providing
inpatient services are not requested to complete a survey.
For purposes of this document, the word “facility” will be used interchangeably when referring
to renal dialysis facilities, renal dialysis centers, or renal transplant centers, as applicable.
Survey Period
The Facility Survey is completed annually. The survey period is January 1 through December 31.
This Facility Survey is to be completed for the period January 1, 2005 through December 31,
2005. Unless specified otherwise, all data entered on the Facility Survey is to cover the entire
survey period. The form should be completed and forwarded to the local ESRD Network.
GENERAL INSTRUCTIONS
Please complete the following information which will be used to update the CMS Dialysis
Facility Compare website. This information should reflect your facility status as of December
31:
Facility Physical Address
Complete this information if your physical address is different from your mailing address.
Number of Dialysis Stations
Provide the number of approved dialysis stations in your facility as of December 31.
Facility Telephone
Provide your facility telephone number including area code.
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Facility Ownership Type
Check the appropriate block for profit or non-profit type of ownership.
Facility Local/National Affiliation/Chain Information
Provide information if your facility is owned or managed by a national corporation, e.g.,
Gambro, Fresenius, etc.
Types of dialysis services offered
Provide information on the types of dialysis services your facility is approved to provide as of
December 31. These are the types of services that are listed on the Dialysis Facility Compare
website; Incenter Hemodialysis, Peritoneal Dialysis and/or Home Hemodialysis Training.
Does your facility offer a dialysis shift that starts at 5:00 p.m. or later?
Provide information as to whether your facility offers dialysis shifts that begins on or after 5:00
as of December 31.

DIALYSIS PATIENTS, TREATMENTS AND STAFFING
(FOR COMPLETION BY DIALYSIS UNITS ONLY)
PATIENT LOAD
All patient and treatment counts requested are to include only the diagnosed chronic ESRD
population; no reversible failure (Acute) patients or treatments may be counted.
All diagnosed chronic ESRD patients treated at the facility should be counted and reported as (1)
regular, continuing caseload (field 03); (2) added to the regular caseload (fields 04A through
07B); or (3) lost from the regular caseload (fields 08A through 13B).
Inclusion of patients in counts should not depend on entitlement determination; newly diagnosed
chronic unit admissions should be included, both for peritoneal or hemodialytic therapy and
transplantation.
NOTE: Any provider who has signed an agreement with a dialysis supplier to provide support
services to Method II home patients should count those patients as part of their regular dialysis
population on the ESRD Facility Survey Form. Please keep this in mind when completing fields
for home dialysis patients.

Patients Receiving Care Beginning of Survey Period
Field 01: Incenter. Enter the number of patients dialyzing in your facility at the beginning of the

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survey period. This number should reflect your “permanent” patient population; i.e., those
patients for whom your facility had ongoing medical responsibility for the routine care of the
patient until he/she was formally transferred elsewhere. Include those of your routine patients
who were hospitalized or were in transient status away from your facility at the beginning of the
survey period.
Field 02: Home. Enter the number of patients followed by your facility; that is, for whom your
facility had the major medical responsibility, (e.g., the facility which provides incenter backup
dialysis, performs necessary medical follow-ups, provides the patient with home dialysis
supplies, or has a written agreement to provide support services to Method II patients). Enter the
number of patients who were dialyzing at home (hemodialysis, continuous ambulatory peritoneal
dialysis, continuous cycling peritoneal dialysis or other dialysis, e.g., intermittent peritoneal
dialysis) at the beginning of the survey period.
Field 03: Total. Enter the sum of fields 01 and 02. This should equal the number of patients on
your facility’s register at the beginning of the survey period.
Additions During the Survey Period
NOTE: This section requires counts for additional incenter and home dialysis patients accepted
during the survey period.
Newly Diagnosed Patients:
Field 04A: Incenter-Started for the First Time Ever. Enter the number of newly diagnosed
ESRD patients who were admitted to your facility as chronic maintenance dialysis patients for
the first time ever during the survey period. This is a count of patients who have begun their
initial course of incenter maintenance dialysis therapy during the survey period and for whom
your facility will have major medical responsibility. Do not include patients who transferred to
your facility from another dialysis facility; that data is to be reported in field 06A.
Field 04B: Home-Started for the First Time Ever. Enter the number of newly diagnosed
ESRD patients who, after being stabilized on dialysis, successfully completed a course of selfdialysis training and began home dialysis (their initial course of home dialysis after training)
during the survey period. If they are still in training at the end of the survey period, report them
in field 04A.

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Restarted Dialysis:
Field 05A: Incenter-Restarted. Enter the number of patients who restarted incenter dialysis
during the survey period. This is a count of persons who had temporarily recovered kidney
function, had discontinued dialysis, or had been lost to follow-up but restarted routine incenter
dialysis during the survey period.
Field 05B: Home—Restarted. Enter the number of patients who restarted home dialysis during
the survey period. This is a count of patients who had temporarily recovered kidney function,
had discontinued dialysis, or had been lost to follow-up but restarted regular home dialysis
during the survey period.
Transferred From Another Facility:
NOTE: Include those patients who received their first outpatient dialysis (or transplant) at a
Non-Medicare facility including a prison or a facility in another country. Do not count patients
who have transferred in for transient treatments (less than 30 days).
Field 06A: Incenter -Transferred from Other Dialysis Unit. Enter the number of patients
admitted to your facility who were formally transferred from another dialysis facility during the
survey period and who are continuing a regular course of dialysis at your facility. A formal
transfer is the transfer of a patient, including his/her medical records, to another facility that will
permanently become the primary care provider.
Field 06B: Home-Transferred from Other Dialysis Unit. Enter the number of home patients
who were formally transferred by another facility during the survey period to your unit for
ongoing medical supervision and responsibility. A formal transfer is the transfer of a patient,
including his/her medical records, to another facility that will permanently become the primary
care provider.
Returned After Transplantation:
NOTE: Do not include dialysis patients who are post transplant and are waiting for their graft to
function. Include only those patients for whom a physician has written a prescription for a
regular course of dialysis (at least 3 times per week).
Field 07A: Incenter -Returned After Transplantation. Enter the number of patients who
returned to incenter dialysis during the survey period after a transplant failure. (Do not include
patients in this field who are on temporary backup dialysis due to an Acute failure episode or
patients receiving dialysis post transplant while waiting for their graft to function.)
Field 07B: Home-Returned After Transplantation. Enter the number of patients who returned
to home dialysis during the survey period after a transplant failure. (Do not include patients in
this field who are on temporary backup dialysis due to an Acute failure episode or patients
receiving dialysis post transplant while waiting for their graft to function.)

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Losses During the Survey Period
NOTE: These fields describe losses to your facility of both incenter and home patients that
occurred during the survey period. For purposes of this survey, “incenter” includes patients who
routinely dialyzed incenter at the time of loss to the reporting facility, and “home” includes
patients who routinely dialyzed at home at the time of loss to the reporting facility.
Deaths:
NOTE: If a patient death occurs within 30 days of stopping dialysis, then submit a CMS2746, Death Notification Form, and count the patient as a death.
Field 08A: Incenter-Deaths. Enter the number of incenter dialysis patients who died during the
survey period. These deaths must be shown in 08A if patient was on incenter dialysis at time of
death.
Field 08B: Home-Deaths. Enter the number of home dialysis patients who died during the
survey period. These deaths must be shown in 08B if patient was on home dialysis at time of
death.
Recovered Kidney Function:
Field 09A: Incenter -Recovered Kidney Function. Enter the number of patients who recovered
function of their native kidneys and ceased chronic incenter dialysis during the survey period.
Field 09B: Home-Recovered Kidney Function. Enter the number of patients who recovered
function of their native kidneys and ceased chronic home dialysis during the survey period.
Transplanted:
NOTE: Any patient receiving a kidney transplant must be listed in this category, even if the
graft never functioned.
Field 10A: Incenter -Received Transplant. Enter the number of patients who received a kidney
transplant during the survey period.
Field 10B: Home-Received Transplant. Enter the number of patients who received a kidney
transplant during the survey period.
Transferred Out:
NOTE: Include patients who left the facility to dialyze elsewhere (at Medicare approved or
non-Medicare approved facility) for more than 30 days. Include patients who have been
involuntarily discharged regardless of where patients received services after discharge. Do not
count patients who were dialyzing at your facility as a short-term transient patient.

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Field 11A: Incenter -Transferred to Other Dialysis Unit. Enter the number of incenter
dialysis patients who permanently transferred to another dialysis facility for their ongoing
dialysis during the survey period; that is, those patients whose ongoing, routine medical
supervision became the responsibility of another dialysis facility.
Field 11B: Home-Transferred to Other Dialysis Unit. Enter the number of home patients who
had been followed by your facility but who are now permanently followed by another home
dialysis program.
Discontinued Dialysis:
NOTE: These fields should contain counts of patients whose last known activity was that they
discontinued dialysis. This would pertain mostly to patients who were lost to the facility at the
end of the survey period, were not lost to follow-up and had not yet expired by December 31 (a
Death Notification Form has not yet been submitted on the patient). You must follow the patient
for 30 days after his/her last dialysis session. If a patient death occurs within 30 days of stopping
dialysis, then submit a CMS-2746, Death Notification Form, and count the patient as a death.
Field 12A: Incenter -Discontinued Dialysis. Enter the number of chronic patients who
permanently discontinued dialysis (excluding those reported in fields 08A, 09A, 10A, 11A and
13A) who had been dialyzing incenter during the survey period.
Field 12B: Home-Discontinued Dialysis. Enter the number of chronic patients who
permanently discontinued dialysis (excluding those reported in fields 08B, 09B, 10B, 11B and
13B) who had been dialyzing at home during the survey period.
Lost to Follow-Up:
NOTE: Do not use this event when a patient has voluntarily discontinued dialysis (report in
Fields 12/A or 12/B) or has transferred out to another facility (report in Field 11/A or 11/B).
Patients should be included only after every effort has been made to locate the patient.
Field 13A: Incenter – Other - Lost to Follow-Up (LTFU). Enter the number of patients, who
had been dialyzing incenter, who left your dialysis program during the survey period, and whose
current status is unknown to your facility (lost to follow-up) Do not include those patients
reported in fields 08A, 09A, 10A, 11A, or 12A.
Field 13B: Home- Other - Lost to Follow-Up (LTFU). Enter the number of patients, followed
by your facility, who had been dialyzing at home, who were removed from your facility’s rolls
during the survey period, and whose current status is unknown (lost to follow-up). Do not
include those patients reported in fields 08B, 09B, 10B, 11B, or 12B.
Patients Receiving Care at the End of the Survey Period
NOTE: DO NOT COUNT A PATIENT IN MORE THAN ONE FIELD. Patients receiving care
at the beginning of the survey period plus the additions during the survey period minus the losses
during the survey period should equal the patients receiving care (remaining) at the end of the
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survey period. Please ensure that field 03 plus field 04A through 07B, minus fields 08A through
13B, equals field 26.
Incenter Dialysis:
NOTE: Patients who are dialyzing incenter, but are performing all dialysis procedures without
the assistance of staff, are to be counted incenter self-dialyzing either in fields 14 or 15. (Since
this is not a large patient population, not all facilities will have patients that fall into this
category.) Treatments for these patients should be counted as outpatient treatments in fields 36 or
37.
Field 14: Hemodialysis. Enter the number of patients who, at the end of the survey period, were
receiving staff-assisted hemodialysis or performing incenter self-hemodialysis.
Field 15: Other Dialysis. Enter the number of patients who, at the end of the survey period,
were receiving dialysis, other than hemodialysis. For example, those patients who are on staffassisted intermittent peritoneal dialysis or performing incenter self- peritoneal dialysis would be
counted in this field.
Self-Dialysis Training:
Field 16: Hemodialysis. Enter the number of patients who are in a self hemodialysis training
program as of the end of the survey period. Patients are to be reported in this category only if the
training is designed to enable them to perform their own self-dialysis incenter or at home.
Field 17: Continuous Ambulatory Peritoneal Dialysis (CAPD). Enter the number of patients
who are in a CAPD training program as of the end of the survey period. Patients are to be
reported in this category only if the training is designed to enable them to independently perform
CAPD.
Field 18: Continuous Cycling Peritoneal Dialysis (CCPD). Enter the number of patients who
are in a CCPD training program as of the end of the survey period. Patients are to be reported in
this category only if the training is designed to enable them to independently perform CCPD.
Field 19: Other Dialysis. Enter the number of patients who are in a self dialysis training
program, e.g., a self intermittent peritoneal dialysis (IPD) training program as of the end of the
survey period. Patients are to be reported in this category only if the training is designed to
enable them to perform their own self-dialysis incenter or at home.
Field 20: Total Incenter. Enter the total number of patients who are incenter status as of the end
of the survey period (the sum of fields 14 through 19).
Home Dialysis
NOTE: Patients who are dialyzing at home with the assistance of staff provided by a dialysis
supplier or facility should be counted as home patients (fields 21 through 24).

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Field 21: Hemodialysis. Enter the number of patients who were hemodialyzing at home as of
the end of the survey period.
Field 22: Continuous Ambulatory Peritoneal Dialysis (CAPD). Enter the number of patients
who are on CAPD as of the end of the survey period.
Field 23: Continuous Cycling Peritoneal Dialysis (CCPD). Enter the number of patients who
are on CCPD as of the end of the survey period.
Field 24: Other Dialysis. Enter the number of patients who are on another type of home dialysis
e.g., intermittent peritoneal dialysis (IPD) as of the end of the survey period.
Field 25: Total Home. Enter the total number of patients who are in home status as of the end of
the survey period (the sum of fields 21 through 24).
Total:
Field 26: Total. Enter the total number of patients on your facility’s register at the end of the
survey period (the sum of fields 20 and 25).
Patient Eligibility Status-End of Survey Period
NOTE: Counts should reflect entitlement only, not based on how reimbursement is made for
dialysis services provided by your facility. For example, a VA (Department of Veterans Affairs)
patient whose reimbursement is made by the VA, but is a Medicare entitled patient, should be
counted in Field 27. Please ensure that the sum of fields 27, 28, and 29 equals field 26, the total
number of patients at the facility at the end of the survey period.
Field 27: Currently Enrolled in Medicare. Enter the number of patients at the end of the survey
period who were enrolled in Medicare. This count should include patients who are Medicare
Secondary Payer beneficiaries or patients enrolled in Medicare HMO/Medicare+Choice.
Field 28: Medicare Application Pending. Enter the number of patients at the end of the survey
period who had Medicare applications pending.
Field 29: Non-Medicare. Enter the number of patients at the end of the survey period who were
not enrolled in Medicare and who did not have Medicare applications pending.
Patients Dialyzing More Than 4 Times Per Week
Note: Report only those patients on hemodialysis as of December 31 and dialyzing more that 4
times per week. Nocturnal dialysis is defined as hemodialysis that takes place while the patient
is sleeping for approximately 8 hours.
Field 30A: Incenter/Day. Enter the number of hemodialysis patients who are dialyzing
incenter, and during the day, for more than 4 times per week.
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Field 30B: Home/Day. Enter the number of hemodialysis patients who are dialyzing at home,
and during the day, for more than 4 times per week.
Field 31A: Incenter/Nocturnal. Enter the number of hemodialysis patients who are dialyzing
incenter and nocturnal for more than 4 times per week.
Field 31B: Home/Nocturnal. Enter the number of hemodialysis patients who are dialyzing at
home and nocturnal for more than 4 times per week.
Vocational Rehabilitation
NOTE: Enter the following information on each of the patients reported based on their activities
at any time during the calendar year (January1 through December 31). Information being
provided is for patients, who as of December 31, are living and have attained the ages of 18
through 54. You can count patients as both attending school and employed either full-time
or part-time.
Field 32: Patients Aged 18 through 54. Enter the number of dialysis patients who, as of
December 31, were ages 18 through 54, and who were dialyzing at your facility.
Field 33: Patients Receiving Services from Voc Rehab. For the dialysis patients counted in
Field 32, enter the number who are receiving Vocational Rehabilitation Services (public or
private). Include any patients for whom any of the following applies:
• Talked with VR personnel AND agreed to be evaluated for services by completing an
application, having medical records requested, or being assigned a counselor.
• Received evaluation services by participating in testing (for example: interest inventories,
skills testing, aptitude testing, work readiness inventories) or by attending an
evaluation/testing center.
• Received vocational counseling, training at a community facility private or public
educational/training center or school.
• Received assistance with job seeking skills, with job placement, or with retaining or
modifying a job through a VR counselor job placement specialist, private or public
agencies.
Field 34: Patients Employed Full-Time or Part-Time. Enter the number of patients who are
employed either full-time or part-time. Include any patient, aged 18 through 54, who received
taxable wages from an employer or who was self-employed and paid taxes on earnings. Count
only those patients who were receiving taxable earnings.
Fields 35: Patients Attending School Full-Time or Part-Time. Enter the number of patients
who are attending school either full-time or part-time. Include any patient, aged 18 through 54,
who was enrolled in any formal education or training program (for example: college, technical
school, GED program, community facility training).

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TREATMENT AND STAFFING
NOTE: The following section (fields 36 and 37) should reflect all outpatient treatments given to
ESRD patients including self-care training treatments and those provided to transients during the
survey year. Please be certain to report treatments to correspond with patients counted at the end
of the survey period in a particular modality. If a situation occurs where a patient is reported at
the end of the survey period but no treatments were provided, please explain why no treatments
were provided in the Remarks section of the survey form. DO NOT INCLUDE ACUTE
TREATMENTS.
Hemodialysis
Field 36: Outpatient Treatments. Enter the number of staff-assisted treatments, training
hemodialysis treatments and treatments performed by self-dialyzing patients, incenter, during the
survey period.
Other
Field 37: Other Treatments. Enter the number of all other types of treatments provided
incenter. For all types of peritoneal dialysis training, report the number of days for which
exchanges were provided. Do not report the number of exchanges and do not report days where
no dialysis treatments or exchanges were furnished. For example, report the number of staffassisted and training intermittent peritoneal (IPD) treatments, CAPD and CCPD training days
and all other number of treatments performed by self-dialyzing patients or training patients,
incenter, during the survey period.
Staffing
Enter the number of Full Time and Part Time staff positions at your facility as of December 31.
Also provide the number of Full Time and Part Time staff positions that are open and not filled
as of December 31.
The following definitions are provided as guidelines in completing this section:
Full Time Position is defined as a position with at least 32 hours employment per week
Part time Position is defined as a position with less than 32 hours per week and includes per
diem staff.
RN:

Staff holding a Registered Nurse degree.

LPN/LVN:

Licensed Practical Nurse, Licensed Vocational Nurse: Staff holding either of
those degrees.

PCT:

Patient Care Technician. Include staff providing direct patient care.

APN:

Advanced Practice Nurse.
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The Advanced Practice Nurse (APN) is a Certified Registered Nurse (RN)
with advanced certification as a nurse practitioner (NP) or a Clinical Nurse
Specialist (CNS) who has met advanced educational and clinical practice
requirements. Do not report Certified Nephrology Nurses (CNNs) in this
category. Do not double count a registered nurse in this category.
Dietitian:

Renal Dietitians. Staff with renal dietitian credentials.

Social Worker: Staff with LCSW, MSW, BSW or other professional social work degrees.
Field 38: Enter the number of Full Time staff as of December 31: a) Registered Nurses, b)
Licensed Practical Nurses/Licensed Vocational Nurses, c) Patient Care Technicians,
d) Advanced Practice Nurses, e) Dietitians, and f) Social Workers.
Field 39: Enter the number of Part Time staff as of December 31: a) Registered Nurses, b)
Licensed Practical Nurses/Licensed Vocational Nurses, c) Patient Care Technicians,
d) Advanced Practice Nurses, e) Dietitians, and f) Social Workers.
Field 40: Enter the number of Full Time staff positions that are open as of December 31: a)
Registered Nurses, b) Licensed Practical Nurses/Licensed Vocational Nurses, c) Patient Care
Technicians, d) Advanced Practice Nurses, e) Dietitians, and f) Social Workers.
Field 41: Enter the number of Part Time staff positions that are open as of December 31: a)
Registered Nurses, b) Licensed Practical Nurses/Licensed Vocational Nurses, c) Patient Care
Technicians, d) Advanced Practice Nurses, e) Dietitians, and f) Social Workers.
Signatures
Part One of the Facility Survey requires signatures, as follows:
Completed by: Enter the date completed and the name, title, and telephone number of the
person who completed the Facility Survey for your facility. This person should be the individual
who the ESRD network or CMS can contact to discuss any information provided in the Facility
Survey.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0447. The time
required to complete this information collection is estimated to average 7 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

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KIDNEY TRANSPLANTS PERFORMED
(FOR COMPLETION BY KIDNEY TRANSPLANT CENTERS ONLY)
NOTE: Every kidney transplant must be reported in this category, even if the transplant
never functioned.
PATIENTS/TRANSPLANTS
Field 42: Patients Who Received Transplant at This Facility. Enter the number of patients
who received a kidney transplant at your facility during the survey period. If a patient received
more than one transplant at your center during the survey period, the patient is to be counted only
once. Total of fields 43 + 44 + 45 + 46.
Patient Eligibility Status of Patients Transplanted During Survey Period
NOTE: Fields 43 through 46 refer to those patients actually transplanted during the survey
period. Ensure that the total of fields 43 through 46 equals the count in field 42. Fields 45 and
46 (Non-Medicare U.S. Residents and Other) makes reference to foreign nationals. A foreign
national is any person who is not a U.S. citizen, and includes permanent resident aliens.
Field 43: Currently Enrolled in Medicare. Enter the number of patients transplanted during the
survey period who were enrolled in Medicare. Count Medicare transplant recipients based on
enrollment rather than primary insurer.
Field 44: Medicare Application Pending. Enter the number of patients transplanted during the
survey period that had Medicare applications pending.
Field 45: Non-Medicare, U.S. Residents. Enter the number of patients transplanted during the
survey period who were not enrolled in Medicare and did not have Medicare applications
pending who were either U.S. citizens or a foreign national U.S. resident.
Field 46: Non-Medicare, Other. Enter the number of patients transplanted during the survey
period who were not enrolled in Medicare, did not have Medicare applications pending, and were
neither a U.S. citizen nor a U.S. resident (e.g., foreign national).
Transplants Performed at This Facility:
Field 47: Transplants Performed at This Facility-Living Related Donor. Enter the number of
living related donor kidney transplants performed at your center during the survey period.
Field 48: Transplants Performed at This Facility-Living Unrelated Donor. Enter the number
of living unrelated donor kidney transplants performed at your center during the survey period.
Field 49: Transplants Performed at This Facility-Deceased Donor. Enter the number of
deceased donor kidney transplants performed at your center during the survey period.

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Field 50: Transplants Performed at This Facility-Total Fields 47, 48 and 49. Enter the sum
of fields 47 + 48 + 49.
Patients Awaiting Transplant:
Field 51: Patients Awaiting Transplant-Dialysis. Enter the number of current dialysis patients
actively awaiting a kidney transplant at your center as of the last day of the survey period. These
patients must (a) be medically able, (b) have given consent, and (c) be on an active transplant
list. This count is limited to individuals awaiting transplant at the reporting center.
Field 52: Patients Awaiting Transplant-Non-Dialysis. Following the criteria described above,
enter the number of non-dialysis patients who are awaiting transplant as of the last day of the
survey period. This is to include patients scheduled for transplant who have not yet initiated a
regular course of dialysis.
Signatures
Part Two of the Facility Survey requires signatures as follows:
Completed by: Enter the date completed and the name, title and telephone number of the person
who completed the Facility Survey for your facility.
REMARKS/COMMENTS
You may include here any remarks or additional information you wish to supply concerning the
information furnished on this survey.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0447. The time
required to complete this information collection is estimated to average 7 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

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