Information Collection

End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E

IC 8067 under ICR 202309-0938-016 · OMB 0938-0448.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0448 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-2746 End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E	Form
CMS-2746 ESRD Death Notification Form CMSForm2746ESRD revised.docx	Form
CMS-2746 ESRD Death Notification Form CMSForm2746ESRD revised clean_V3.docx	Form
2746Crosswalk508.docx.pdf Crosswalk	IC Document
2746Crosswalk508.docx.pdf Crosswalk	IC Document
CMSForm2746ESRD redline.docx Redline	IC Document
CMSForm2746ESRD redline.docx redline	IC Document
CMSForm2746ESRD revised redline_V3 2-29-24.docx redline	IC Document

IC Title:

End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 401.. 20 CFR 422.Subpart E 45 CFR 5.5b 42 CFR 405.2133

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	CMS-2746	ESRD Death Notification Form	CMSForm2746ESRD revised clean_V3.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,726

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	101,491	9,468	92,023
Annual IC Time Burden (Hours)	50,746	4,734	46,012
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	2746Crosswalk508.docx.pdf	09/27/2023
redline	CMSForm2746ESRD redline.docx	02/29/2024
redline	CMSForm2746ESRD revised redline_V3 2-29-24.docx	02/29/2024

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