Information Collection

IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)

IC 257115 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10750 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction
CMS-10750 NW 1 Collaborator Survey CMS-10750 ESRD NW 1 Draft 2020 Collaborator Survey.pdf	Form and Instruction
CMS-10750 NW 1 Collaborator Survey CMS-10750 ESRD NW 1 Draft 2020 Collaborator Survey.pdf	Form and Instruction
CMS-10750 NW 2 Collaborator Survey CMS-10750 ESRD NW 2 Draft 2020 Collaborator Survey.pdf	Form and Instruction
CMS-10750 NW 2 Collaborator Survey CMS-10750 ESRD NW 2 Draft 2020 Collaborator Survey.pdf	Form and Instruction
CMS-10750 NW 6 Collaborator Survey CMS-10750 ESRD NW 6 Draft 2020 Collaborator Survey.pdf	Form and Instruction
CMS-10750 NW 6 Collaborator Survey CMS-10750 ESRD NW 6 Draft 2020 Collaborator Survey.pdf	Form and Instruction
CMS-10750 NW 9 Collaborator Survey CMS-10750 ESRD NW 9 Draft 2020 Collaborator Survey.pdf	Form and Instruction
CMS-10750 NW 9 Collaborator Survey CMS-10750 ESRD NW 9 Draft 2020 Collaborator Survey.pdf	Form and Instruction
CMS-10750 Generic_Clearance_Submission_IPRO ESRD.doc.docx CMS-10750 Generic_Clearance_Submission_IPRO ESRD.doc	IC Document
CMS-10750 Generic_Clearance_Submission_IPRO ESRD.doc.docx CMS-10750 Generic_Clearance_Submission_IPRO ESRD.doc	IC Document

IC Title:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10750	NW 1 Collaborator Survey	CMS-10750 ESRD NW 1 Draft 2020 Collaborator Survey.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10750	NW 2 Collaborator Survey	CMS-10750 ESRD NW 2 Draft 2020 Collaborator Survey.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10750	NW 6 Collaborator Survey	CMS-10750 ESRD NW 6 Draft 2020 Collaborator Survey.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10750	NW 9 Collaborator Survey	CMS-10750 ESRD NW 9 Draft 2020 Collaborator Survey.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 560

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	560	560
Annual IC Time Burden (Hours)	93	93
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10750 Generic_Clearance_Submission_IPRO ESRD.doc	CMS-10750 Generic_Clearance_Submission_IPRO ESRD.doc.docx	11/25/2022

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