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 202505-0938-001 · OMB 0938-0448.

Documents and Forms

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
Form CMS-2746 ESRD Death Notification Form 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 CMS-2746 clean.pdf Form
CMS-2746 ESRD Death Notification Form CMS-2746 clean.pdf Form
CMS-2746 EO14168 markup .pdf redline of CMS-2746 IC Document
CMS-2746 EO14168 markup .pdf redline of CMS-2746 IC Document

Information Collection (IC) Details

View Information Collection (IC)

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

Information Collection 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	CMS-2746 clean.pdf		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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	101,491	101,491
Annual IC Time Burden (Hours)	50,746	50,746
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
redline of CMS-2746	CMS-2746 EO14168 markup .pdf	05/02/2025

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

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