Form CMS-2744A&B END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD

Form Approved
OMB No. 0938-0447

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FOR THE PERIOD

END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY (DIALYSIS UNITS ONLY)

Facility Physical Address

(If different than mailing address) Suite/Room Street

City

Number of Dialysis Stations:

Facility Telephone: (

Facility Ownership Type: ■ Profit

■ Non-Profit

Facility Local/National Affiliation/Chain Information

State/Zip Code

)

( i.e. Satellite Healthcare, etc)

Types of dialysis services offered:

■ Incenter Hemodialysis

■ Peritoneal Dialysis

■ Home Hemodialysis Training

Does your facility offer a dialysis shift that starts at 5:00 p.m. or later?

■ Yes

■ No

DIALYSIS PATIENTS AND TREATMENTS
DIALYSIS PATIENTS
Additions During Survey Period
Started
Restarted
for first
time ever

Patients Receiving Care
Beginning of Survey Period
Incenter

Home

Total
Fields 01
thru 02

01

02

03

Losses During Survey Period

Transferred
Returned
from
other
after
dialysis transplant
unit

Deaths

Recovered Received
kidney
function transplant

Transferred
Disto other
continued
dialysis
dialysis
unit

Other
(LTFU)

Incenter
Home
04A
04B

05A
05B

06A
06B

08A
08B

07A
07B

09A
09B

10A
10B

11A
11B

12A
12B

13A
13B

Patients Receiving Care at End of Survey Period

Incenter
Dialysis

Total
Incenter
Dialysis

Self-Dialysis Training

Home Dialysis

Total
Home
Dialysis

Total
Patients

HemoDialysis

Other

HemoDialysis

CAPD

CCPD

Other

Fields 14
thru 19

HemoDialysis

CAPD

CCPD

Other

Fields 21
thru 24

Fields 20
and 25

14

15

16

17

18

19

20

21

22

23

24

25

26

Patient Eligibility Status
End of Survey Period
Currently
Medicare
Nonenrolled
application
Medicare
in
pending
Medicare

27

28

Hemodialysis Patients Dialyzing
More Than 4 Times Per Week
Setting

Vocational Rehabilitation

Day Nocturnal

Incenter
Home
30A
30B

29

31A
31B

Patients
aged 18
through
64

Patients
aged 65
and older

32

33

Patients
Patients
Patients
receiving
attending
Employed
services
school
full-time or
from Voc
full-time or
part-time
Rehab
part-time

34

35

36

TREATMENT AND STAFFING
Staffing
Incenter Dialysis Treatments
(Include Training Treatments)

COMPLETED BY (Name)

Hemodialysis

Other

37

38

Position
a. RNs
b. LPN/LVNs
c. PCTs
d. APNs
e. Dietitians
f. Social Workers

DATE

Number of Staff

Number of Open Pos.

Full Time

Part Time

Full Time

Part Time

39

40

41

42

TITLE

TELEPHONE NO.

REMARKS REGARDING INFORMATION PROVIDED ON THIS SURVEY SHOULD BE ENTERED ON THE LAST PAGE OF THE SURVEY
This report is required by law (42 USC 426; 42 CFR 405.2133). Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974
(5 USC 5520; 45 CFR, Part 5a).
Form CMS-2744A (xx/xx)

Form Approved
OMB No. 0938-0447

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FOR THE PERIOD

END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY (TRANSPLANT CENTERS ONLY)

KIDNEY TRANSPLANTS PERFORMED
PATIENTS TRANSPLANTED
AND DONOR TYPE

TO BE COMPLETED BY
KIDNEY TRANSPLANT CENTERS ONLY
Eligibility Status of Patients
Transplanted at this Facility
During the Survey Period

Patients
who
received
transplant
at this
facility

Non-Medicare
Currently Medicare
enrolled
application
U.S.
in
Other
Medicare pending Resident

43

44

45

46

47

Transplant Procedures Performed
at This Facility
Living
Related
Donor
48

Patients Awaiting
Transplant

Total
Living
Deceased
Unrelated
Fields 48
Donor
Donor
thru 50
49

50

Dialysis

51

52

Nondialysis

53

REMARKS/COMMENTS

COMPLETED BY (Name)

DATE

TITLE

TELEPHONE NO.

This report is required by law (42 USC 426; 42 CFR 405.2133). Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974
(5 USC 5520; 45 CFR, Part 5a).
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 (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average 4
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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any
documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden
approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to
submit your documents, please contact the ESRD Network in your region.
Form CMS-2744B (xx/xx)