Information Collection

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

IC 214103 under ICR 201412-0938-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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_REVISED (12-12-14).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: Modified

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
	Requested	Previously Approved
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_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.