IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.