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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0447 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-2744A End Stage Renal Disease Medical Information System ESRD Facility Survey and Supporting Regulations in 42 CFR 405.2133 Form
CMS-2744.Current facility survey instructions.pdf Instruction
CMS-2744A END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD CMS-2744A.pdf Form
CMS-2744B END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD CMS-2744B.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	End Stage Renal Disease Medical Information System ESRD Facility Survey and Supporting Regulations in 42 CFR 405.2133	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 422.Subpart E 45 CFR 5.5b 42 CFR 405.2133 20 CFR 401..

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-2744A	END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY	CMS-2744A.pdf	Yes	Yes	Fillable Fileable
Form	CMS-2744B	END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY)	CMS-2744B.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-2744.Current facility survey instructions.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: End Stage Renal Disease (ESRD) Program Management and Medical Information System (PMMIS)	FR Citation: 72 FR 26126

Number of Respondents: 5,964	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,964	5,964
Annual IC Time Burden (Hours)	47,712	47,712
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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