Information Collection

End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60

IC 8003 under ICR 202205-0938-004 · OMB 0938-0360.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-3427 End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60	Form and Instruction
CMS-3427 ESRD Application and Survey and Certification Report CMS 3427 ESRD Application-Notification and Survey- Certification Report -.pdf	Form and Instruction
CMS-3427 ESRD Application and Survey and Certification Report CMS 3427 ESRD Application-Notification and Survey- Certification Report -.pdf	Form and Instruction
CMS 3427 Crosswalk of Changes (508) 110119.docx Crosswalk	IC Document
CMS 3427 Crosswalk of Changes (508) 110119.docx Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-3427	ESRD Application and Survey and Certification Report	CMS 3427 ESRD Application-Notification and Survey- Certification Report -.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,601

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,601	128	2,473
Annual IC Time Burden (Hours)	866	42	824
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS 3427 Crosswalk of Changes (508) 110119.docx	02/11/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.