View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0080	ICR Reference No: 202101-0938-007
Status: Historical Active	Previous ICR Reference No: 201707-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13 (CMS-43)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/03/2021
	Date Received in OIRA: 01/15/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2024	36 Months From Approved	06/30/2021
Responses	20,382	0	25,000
Time Burden (Hours)	8,560	0	10,400
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	20,382	25,000	-4,618
Annual Time Burden (Hours)	8,560	10,400	-1,840
Annual Cost Burden (Dollars)	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 annual respondents decreased from 25,000 to 20,382. This continues in the downward trend from the previous iteration.

Annual Cost to Federal Government: $459,731

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. Yes

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. Yes

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

Agency Contact: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

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