(CMS-3427) End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-3427 End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60 Form and Instruction	Modified
CMS Response to Public Comments Received for CMS 3427.docx Supplementary Document	2020-02-11
Supporting Statement - Part A CMS-3427 Clean(508)110119.docx Supporting Statement A	2020-02-11

IC Document Collections

IC ID	Document Title	Status
8003	End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0360	ICR Reference No: 202002-0938-003
Status: Active	Previous ICR Reference No: 201603-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: (CMS-3427) End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/19/2020
	Date Received in OIRA: 02/12/2020
Terms of Clearance: In the next submission, CMS demonstrate progress in creating an online form.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2022	36 Months From Approved
Responses	2,473	0	0
Time Burden (Hours)	824	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This form is a facility identification and screening measurement used to initiate the certification and recertification of ESRD facilities.

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Authorizing Statute(s): PL: Pub.L. 92 - 602 2991 Name of Law: Social Security Act
  

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:
	84 FR 57734	10/28/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 7306	02/07/2020
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
End Stage Renal Disease Application and Survey and Certification Report Form and Supporting Regulations 42 CFR 488.60	CMS-3427	ESRD Application and Survey and Certification Report

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ICR Summary 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	2,473	0	0	0	427	2,046
Annual Time Burden (Hours)	824	0	0	0	142	682
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: The number of respondents increased from 2,046 to 2,473. The burden hours increased from 681 hours to 824 hours. The annual cost burden increased by $49,969 to $79,022 from $29,053due to the increase in number of respondents, burden hours and facility administrator wage increase.

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Annual Cost to Federal Government: $183

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? Uncollected

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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: 02/12/2020

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