End Stage Renal Disease Grievant Satisfaction Survey

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⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.