Information Collection

End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E

IC 8067 under ICR 201905-0938-015 · OMB 0938-0448.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0448 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-2746 End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E Form
CMS-2746 ESRD Death Notification Form Form CMS-2746-508.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-2746	ESRD Death Notification Form	Form CMS-2746-508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,311	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	92,023	17,023	75,000
Annual IC Time Burden (Hours)	46,012	8,512	37,500
Annual IC Cost Burden (Dollars)	0	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.