Information Collection

Evaluation of Patient Satisfaction and Experience of Care for Medicare Beneficiaries with ESRD

IC 204531 under ICR 201210-0938-007 · OMB 0938-1206.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_B_08_02_12.pdf	Instruction
Attachment_C_03-13-12.pdf	Instruction
ESRD_Stakeholder_Interview_Recruiting_Script_Phone_and_Email.pdf	Instruction
ESRD_survey_draft_cover_letter_080212.pdf ESRD Cover Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	Attachment_B_08_02_12.pdf	No	No	Paper Only
Instruction	Attachment_C_03-13-12.pdf	No	No	Paper Only
Instruction	ESRD_Stakeholder_Interview_Recruiting_Script_Phone_and_Email.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,540

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,540	2,540
Annual IC Time Burden (Hours)	662	662
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ESRD Cover Letter	ESRD_survey_draft_cover_letter_080212.pdf	09/24/2012

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