End Stage Renal Disease Quality Reporting System (EQRS) Customer Satisfaction and Task Prioritization Survey for the EQRS Release 1.0 Project (CMS-10626)

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⚠️ Notice: This information collection may be referencing outdated material.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 CMS-10626 End Stage Renal Disease Quality Reporting System (EQRS) Customer Satisfaction and Task Prioritization Survey for the EQRS Release 1.0 Project (CMS-10626) Form and Instruction
CMS-10626 CrownWeb Facility User Survey CMS-10626 PRA_Generic_Clearance_Submission_EQRS_Facility_Dashboard_Survey_revised2.docx Form and Instruction
CMS-10626 PRA_Generic_Clearance_Submission_EQRS_Facility_Dashboard_Survey_revised2.docx CMS-10626 PRA_Generic_Clearance_Submission_EQRS_Facility_Dashboard_Survey_revised2 IC Document

Information Collection (IC) Details

IC Title:	End Stage Renal Disease Quality Reporting System (EQRS) Customer Satisfaction and Task Prioritization Survey for the EQRS Release 1.0 Project (CMS-10626)	Agency IC Tracking Number:

IC Status: New

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	CMS-10626	CrownWeb Facility User Survey	CMS-10626 PRA_Generic_Clearance_Submission_EQRS_Facility_Dashboard_Survey_revised2.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 15

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10626 PRA_Generic_Clearance_Submission_EQRS_Facility_Dashboard_Survey_revised2	CMS-10626 PRA_Generic_Clearance_Submission_EQRS_Facility_Dashboard_Survey_revised2.docx	04/30/2019

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