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

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.