Information Collection

End Stage Renal Disease Grievant Satisfaction Survey

IC 235903 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⚠️ Notice: This information collection may be referencing outdated material.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:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10415.GenIC #5 End Stage Renal Disease Grievant Satisfaction Survey	Form and Instruction
CMS-10415.GenIC #5 End Stage Renal Disease (ESRD) Grievant Satisfaction Sur ESRD Grievant Satisfaction Survey.pdf	Form and Instruction
Change Justification_ESRD Grievant Satisfaction Survey.pdf Change Justification_ESRD Grievant Satisfaction Survey	IC Document
Pre-Notification Letter_Version 2.0.pdf Pre-Notification Letter_Version 2.0	IC Document
Generic Clearance Submission Template_ESRD Grievant Satisfaction Survey.docx Generic Clearance Submission Template_ESRD Grievant Satisfaction Survey.docx	IC Document

IC Title:

End Stage Renal Disease Grievant Satisfaction Survey

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-10415.GenIC #5	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey	ESRD Grievant Satisfaction Survey.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
Change Justification_ESRD Grievant Satisfaction Survey	Change Justification_ESRD Grievant Satisfaction Survey.pdf	04/30/2019
Pre-Notification Letter_Version 2.0	Pre-Notification Letter_Version 2.0.pdf	04/30/2019
Generic Clearance Submission Template_ESRD Grievant Satisfaction Survey.docx	Generic Clearance Submission Template_ESRD Grievant Satisfaction Survey.docx	04/30/2019

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