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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 214103 under ICR 201412-0938-006 · OMB 0938-1185.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

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

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

Health Health Care Services

 

384 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 384 0 0 0 0 384
Annual IC Time Burden (Hours) 77 0 0 0 0 77
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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_REVISED (12-12-14).doc 12/17/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.