Crosswalk

Revisions to Form CMS-2744A; OMB 0938-0447; END STAGE RENAL DISEASE
MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (DIALYSIS
UNITS ONLY)
Issue # Section

Change

Reason for Change

Burden Affect

Age for Vocational
Rehab changed to
align with the Social
Security retirement
age
Age for Vocational
Rehab changed to
align with the Social
Security retirement
age
Gambro no longer
operates across the
U.S.

N/A

1

Vocational
Rehab

Deleted “Patients Aged 18 through
54”. Changed to “Patients Aged 18
through 64”

2

Vocational
Rehab

Added “Patients aged 65 and older”

3

Facility
Local/Nati
onal
Affiliation/
Chain
Informatio
n

Deleted “Gambro”. Changed to
“Satellite Healthcare”.

N/A

N/A

3

PRA
Disclosure
Statement

Added “****CMS
Disclosure****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 09380447 (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.

Required verbiage
for PRA Disclosure
Statement

N/A