End Stage Renal Disease Death Notification (CMS-2746)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-2746 ESRD Death Notification Form	Form	Modified	Available
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	Modified	Repair queued
CMS-2746 Non Substantive Change Memo EO14168 -5-14-25.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-05-14	Available
CMS-2746 Non Substantive Change Memo EO14168 -5-14-25.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-05-14	Repair queued
CMS-2746 Supporting Stmt. EO14168 clean v1.docx	Supporting Statement A	Uploaded 2025-05-02	Available
CMS-2746 Supporting Stmt. EO14168 clean v1.docx	Supporting Statement A	Uploaded 2025-05-02	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8067	End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E	Form	Modified	ESRD Death Notification Form
8067	End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E	Form	Modified

ICR Details

OMB Control No: 0938-0448	ICR Reference No: 202505-0938-001
Status: Active	Previous ICR Reference No: 202309-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: End Stage Renal Disease Death Notification (CMS-2746)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/29/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/14/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2027	03/31/2027	03/31/2027
Responses	101,491	0	101,491
Time Burden (Hours)	50,746	0	50,746
Cost Burden (Dollars)	0	0	0

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Abstract: The primary purpose of the ESRD Death Notification is to collect demographic characteristics and cause of death regarding an ESRD patient. It is to be completed within 2 weeks of the date of death of an ESRD patient. If the patient was a dialysis patient, the dialysis facility last responsible for the patient’s maintenance dialysis (or home dialysis) must complete this form. If the patient was a transplant patient, the transplant center is responsible for completing this form.

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Authorizing Statute(s): PL: Pub.L. 95 - 292 226 Name of Law: The ESRD Amendments of 1978
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 45218	07/14/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 65689	09/25/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
End Stage Renal Disease Death Notification, P.L. 95-292; 42 CFR 405.2133; 45 CFR 5,5b; 20 CFR Parts 401, 422E	CMS-2746	ESRD Death Notification Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	101,491	101,491	0	0	0	0
Annual Time Burden (Hours)	50,746	50,746	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is a change in total estimated burden hours of 4,734 (50,746 estimated hours – 46,012 previously estimated hours) due to an increase in submission of CMS-2746 forms by 9,468 submissions (101,491 submissions from January 1, 2021 thru December 31,2021 – 92,023 submissions from January 1, 2017 thru December 31, 2017).

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Annual Cost to Federal Government: $12,686,380

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 05/14/2025

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