Information Collection

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

IC 8062 under ICR 201612-0938-024 · OMB 0938-0447.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.