Information Collection

End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2

IC 219438 under ICR 201512-0938-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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) - Round 2	Form and Instruction
GenIC#5 ESRD Greivant Satisfaction Survey Version 2.0 ESRD Grievant Satisfaction Survey_Version 2.0.pdf	Form and Instruction
Pre-Notification Letter_Version 2.0.pdf Pre-Notification Letter_Version	IC Document
Generic Clearance Submission Template_ESRD Grievant Satisfaction Survey.docx Generic Clearance Submission Template_ESRD Grievant Satisfaction Survey	IC Document

IC Title:

End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2

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 Greivant Satisfaction Survey Version 2.0	ESRD Grievant Satisfaction Survey_Version 2.0.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	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-Notification Letter_Version	Pre-Notification Letter_Version 2.0.pdf	12/29/2015
Generic Clearance Submission Template_ESRD Grievant Satisfaction Survey	Generic Clearance Submission Template_ESRD Grievant Satisfaction Survey.docx	12/29/2015

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