The ESRD Network Peer Mentoring Program (CMS-10768)

ICR 202110-0938-004


Federal Form Document

Forms and Documents
Form and Instruction
Supporting Statement A
IC Document Collections
ICR Details
Received in OIRA
The ESRD Network Peer Mentoring Program (CMS-10768)
New collection (Request for a new OMB Control Number)   No
Regular 10/12/2021
  Requested Previously Approved
36 Months From Approved
75 0
19 0
0 0

The ESRD Network Peer Mentoring Program is voluntary program designed to provide patient peer support to people with kidney disease. In part, the peer support is beneficial because patients can give each other something most practitioners do not have, lived experience with kidney disease. The support and perspective of someone who has “been there” can help people cope better with their circumstances. Peer mentors and mentees will complete an online application form via JIRA/Confluence. Information collection will be stored in an ATO approved location on the HICQS server. The collection includes: First and Last Name, City, State, Email address, Phone Number, best time of day to be contacted, age range (not specific age), length of time range (not specific years) as an ESRD patient, current treatment modality, facility name, city, state, zip code, prefer to be a mentor or mentee, peer gender preference, topics of interest (new to dialysis, ESRD overview, home modalities, transplant), hobbies, skills, vocation, preferred language, internet access, and disposition towards meeting and conversations with new people. The information collected on the ESRD Network Program Peer Mentoring Peer Application will be used solely for the purpose of matching mentors and mentees based on the information collected.

EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards

Not associated with rulemaking

  86 FR 37756 07/16/2021
86 FR 54980 10/05/2021

IC Title Form No. Form Name
Patient Peer Mentoring Progam Application CMS-10768 Patient Peer Mentoring Program Application

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 75 0 0 75 0 0
Annual Time Burden (Hours) 19 0 0 19 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
This is a new information collection.

Denise King 410 786-1013 [email protected]


On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

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