Information Collection

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

IC 235896 under ICR 201904-0938-017 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material.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

2022-11-29 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
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

View Information Collection (IC)

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:

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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
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.