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 addressed by the ESRD 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 in early spring. The survey period is January 1
through December 31 of the previous year. 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.,
Satellite Healthcare, 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; In-center 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 (field 03) 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: In-center. Enter the number of patients that were dialyzing in your facility, as of
January 1, of the survey period.
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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 routine patients who were hospitalized or
were in transient status away from your facility as of January 1, 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 in-center 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), as of January 1, 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, as of January 1of the survey period.
Additions During the Survey Period
NOTE: This section requires counts for additional in-center 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 in-center 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 successfully completed a course of self-dialysis 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: In-center—Restarted. Enter the number of patients who restarted in-center 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 in-center
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: In-center —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 dialysis 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
dialysis provider.
Returned After Transplantation:
NOTE: Do not include dialysis patients who were post transplant and were waiting for their
graft to function. Include only those patients for whom a physician had written a prescription for
a regular course of dialysis (at least 3 times per week).
Field 07A: In-center—Returned After Transplantation. Enter the number of patients who
returned to in-center dialysis during the survey period after a transplant failure. (Do not include
patients in this field who were on temporary backup dialysis due to an Acute failure episode or
patients who were 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 were on temporary backup dialysis due to an Acute failure episode or
patients who were 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 in-center and home patients that
occurred during the survey period. For purposes of this survey, “in-center” includes patients who
routinely dialyzed in-center 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 occurred within 30 days of stopping dialysis, then submit a
CMS-2746, Death Notification Form, and count the patient as a death.
Field 08A: In-center—Deaths. Enter the number of in-center dialysis patients who died during
the survey period. These deaths must be shown in 08A if patient was on in-center 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: In-center —Recovered Kidney Function. Enter the number of in-center dialysis
patients who recovered function of their native kidneys and ceased in-center dialysis during the
survey period.
Field 09B: Home—Recovered Kidney Function. Enter the number of home dialysis patients
who recovered function of their native kidneys and ceased home dialysis during the survey
period.
Transplanted:
NOTE: Any patient who received a kidney transplant, during the survey period must be listed
in this category, even if the graft never functioned.
Field 10A: In-center —Received Transplant. Enter the number of in-center dialysis patients
who received a kidney transplant, during the survey period.
Field 10B: Home—Received Transplant. Enter the number of home dialysis patients who
received a kidney transplant, during the survey period.
Transferred Out:
NOTE: Include patients who left the facility to dialyze elsewhere (at a Medicare approved or a
non-Medicare approved facility) for more than 30 days. Include patients who had 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: In-center —Transferred to Other Dialysis Unit. Enter the number of in-center
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 dialysis
patients who had been followed by your facility but, permanently transferred to another home
dialysis program, during the survey period.
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 was not deceased 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: In-center —Discontinued Dialysis. Enter the number of in-center dialysis patients
who permanently discontinued dialysis (excluding those reported in fields 08A, 09A, 10A, 11A
and 13A), during the survey period.
Field 12B: Home—Discontinued Dialysis. Enter the number of home dialysis patients who
permanently discontinued dialysis (excluding those reported in fields 08B, 09B, 10B, 11B and
13B), 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 in Field 13A or 13B, 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, left your dialysis program and whose current status was unknown to
your facility (lost to follow-up), during the survey period. 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 was 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.
In-center Dialysis:
NOTE: Patients who are dialyzing in-center but, are performing all dialysis procedures without
the assistance of staff, are to be counted 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 in-center 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 were on staffassisted intermittent peritoneal dialysis or performing in-center self- peritoneal dialysis would be
counted in this field.
Self-Dialysis Training:
Field 16: Hemodialysis. Enter the number of patients who were 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 in-center or at home.
Field 17: Continuous Ambulatory Peritoneal Dialysis (CAPD). Enter the number of patients
who were 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
were 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 were 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 in-center or at home.
Field 20: Total In-center. Enter the total number of patients who were in-center status, as of the
end of the survey period (the sum of fields 14 through 19).
Home Dialysis
NOTE: Patients who were 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 were on CAPD, as of December 31 of the survey period.
Field 23: Continuous Cycling Peritoneal Dialysis (CCPD). Enter the number of patients who
were on CCPD, as of December 31 of the survey period.
Field 24: Other Dialysis. Enter the number of patients who were on another type of home
dialysis, e.g., intermittent peritoneal dialysis (IPD), as of December 31 of the survey period.
Field 25: Total Home. Enter the total number of patients who were in home status, as of
December 31 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, as of December 31
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, who were dialyzing more
than 4 times per week. Nocturnal dialysis is defined as hemodialysis that takes place while the
patient is sleeping for approximately 8 hours.
Field 30A: In-center/Day. Enter the number of hemodialysis patients who were dialyzing, at
the end of the survey period, in-center 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 at the end of the survey
period, were dialyzing at home and during the day, for more than 4 times per week.
Field 31A: In-center/Nocturnal. Enter the number of hemodialysis patients, who at the end of
the survey period, were dialyzing in-center and nocturnal for more than 4 times per week.
Field 31B: Home/Nocturnal. Enter the number of hemodialysis patients, who at the end of the
survey period, were 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 during the survey period (January1 through December 31). Information being
provided is for patients, who as of December 31, were living and had attained the ages of
18 through 64. You can count patients, as both attending school and employed either fulltime or part-time.
Fields 32/33: Patients Aged 18 through 64. Enter the number of dialysis patients who, as of
the end of the survey period, were ages 18 through 64, and were dialyzing at your facility.
Field 34: Patients Receiving Services from Vocational Rehab. For the dialysis patients
counted in Fields 32/33, enter the number who were receiving Vocational Rehabilitation
Services (public or private), during the survey period (January 1 through December 31).
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 35: Patients Employed Full-Time or Part-Time. Enter the number of patients who
were employed either full-time or part-time, during the survey period. Include any patient,
aged 18 through 64 (Fields 32/33), 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 36: Patients Attending School Full-Time or Part-Time. Enter the number of patients
who were attending school either full-time or part-time, during the survey period. Include any
patient, aged 18 through 64 (Fields 32/33), 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 37 and 38) 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 37: Outpatient Treatments. Enter the number of staff-assisted treatments, training
hemodialysis treatments and treatments performed by self-dialyzing patients, in-center, during
the survey period.
Other
Field 38: 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 39: 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 40: 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 41: 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 42: 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 (Expires
XX/XX/XXXX). This is a mandatory information collection. 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.

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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 43: 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 44 + 45 + 46 + 47.
Patient Eligibility Status of Patients Transplanted During Survey Period
NOTE: Fields 44 through 47 refer to those patients actually transplanted during the survey
period. Ensure that the total of fields 44 through 47 equals the count in field 43. Fields 46 and
47 (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 44: Currently Enrolled in Medicare. Enter the number of patients transplanted during
the survey period who were enrolled in Medicare, at the time of transplant. Count Medicare
transplant recipients based on enrollment rather than primary insurer.
Field 45: Medicare Application Pending. Enter the number of patients transplanted during the
survey period that had Medicare applications pending, at the time of transplant.
Field 46: Non-Medicare, U.S. Residents. Enter the number of patients transplanted during the
survey period who, at the time of transplant, 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 47: Non-Medicare, Other. Enter the number of patients transplanted during the survey
period who, at the time of transplant, 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 48: Transplants Performed at This Facility-Living Related Donor. Enter the number of
living related donor kidney transplants performed at your center, as of the last day of the survey
period.
Field 49: Transplants Performed at This Facility-Living Unrelated Donor. Enter the number
of living unrelated donor kidney transplants performed at your center, as of the last day of the
survey period.
Field 50: Transplants Performed at This Facility-Deceased Donor. Enter the number of
deceased donor kidney transplants performed at your center, as of the last day of the survey
period.
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Field 51: Transplants Performed at This Facility-Total Fields 48, 49 and 50. Enter the sum
of fields 48 + 49 + 50.
Patients Awaiting Transplant:
Field 52: Patients Awaiting Transplant—Dialysis. Enter the number of 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 53: Patients Awaiting Transplant—Non-Dialysis. Following the criteria described
above, enter the number of non-dialysis patients who were awaiting transplant, as of the last day
of the survey period. This is to include patients scheduled for transplant who had 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 (Expires
XX/XX/XXXX). This is a mandatory information collection. 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.

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