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

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

⚠️ Notice: This information collection may be referencing outdated material.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) - 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

Information Collection (IC) Details

IC Title:	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2	Agency IC Tracking Number:

IC Status: Unchanged

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 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 %

	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-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.