The ESRD Network Peer Mentoring Program (CMS-10768)

Forms and Documents

Document Name	Status
Form CMS-10768 Patient Peer Mentoring Progam Application Form and Instruction	New
CMS-10768_Supporting Statement 5-12-21.docx Supporting Statement A	2021-10-12

IC Document Collections

IC ID	Document Title	Status
249687	Patient Peer Mentoring Progam Application Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202110-0938-004
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: The ESRD Network Peer Mentoring Program (CMS-10768)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/12/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	75	0
Time Burden (Hours)	19	0
Cost Burden (Dollars)	0	0

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Abstract: The ESRD Network Peer Mentoring Program is voluntary program designed to provide patient peer support to people with kidney disease. In part, the peer support is beneficial because patients can give each other something most practitioners do not have, lived experience with kidney disease. The support and perspective of someone who has “been there” can help people cope better with their circumstances. Peer mentors and mentees will complete an online application form via JIRA/Confluence. Information collection will be stored in an ATO approved location on the HICQS server. The collection includes: First and Last Name, City, State, Email address, Phone Number, best time of day to be contacted, age range (not specific age), length of time range (not specific years) as an ESRD patient, current treatment modality, facility name, city, state, zip code, prefer to be a mentor or mentee, peer gender preference, topics of interest (new to dialysis, ESRD overview, home modalities, transplant), hobbies, skills, vocation, preferred language, internet access, and disposition towards meeting and conversations with new people. The information collected on the ESRD Network Program Peer Mentoring Peer Application will be used solely for the purpose of matching mentors and mentees based on the information collected.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

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:
	86 FR 37756	07/16/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 54980	10/05/2021
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Patient Peer Mentoring Progam Application	CMS-10768	Patient Peer Mentoring Program Application

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ICR Summary of Burden

	Total Request	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	75	0	0	75	0	0
Annual Time Burden (Hours)	19	0	0	19	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $1,728

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: 10/12/2021

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