Information Collection

End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)

IC 214103 under ICR 201210-0938-003 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form GenIC #5 End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)	Form and Instruction
GenIC #5 ESRD Grievant Satisfaction Survey ESRD Grievant Satisfaction Survey_11 25 14.pdf	Form and Instruction
Pre-Notificaiton Letter_11 25 14.pdf Pre-Notificaiton Letter	IC Document
Pilot Survey Findings Report v2_100814.pdf Pilot Survey Findings Report	IC Document
Generic Clearance Submission Template_ESRD Grievance Survey_FINAL.doc Generic Clearance Submission Template_ESRD Grievance Survey	IC Document

IC Title:

End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	GenIC #5	ESRD Grievant Satisfaction Survey	ESRD Grievant Satisfaction Survey_11 25 14.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 384

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	384	384
Annual IC Time Burden (Hours)	77	77
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Pre-Notificaiton Letter	Pre-Notificaiton Letter_11 25 14.pdf	12/02/2014
Pilot Survey Findings Report	Pilot Survey Findings Report v2_100814.pdf	12/02/2014
Generic Clearance Submission Template_ESRD Grievance Survey	Generic Clearance Submission Template_ESRD Grievance Survey_FINAL.doc	12/02/2014

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