DOCUMENTATION FOR THE GENERIC CLEARANCE

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0938-NEW)
TITLE OF INFORMATION COLLECTION:  
J.9 Network Satisfaction Survey
According to the Budget Reconciliation Act of 1986, the term “Network” refers to the End-Stage Renal Disease (ESRD) Network contractor, which shall be a QIO-like entity. 

PURPOSE:  

The purpose of this survey is to evaluate satisfaction with technical assistance and education provided to dialysis facility staff and patients by the ESRD Networks. CMS will use this information to analyze the impact of the ESRD Network program in the quality improvement for ESRD patient care.

Based on the statutory authority in Title XVIII of the Social Security Act; The statutory provisions originated with Section 299I of Public Law 92-603 which created the National End Stage Renal Disease (ESRD) Program that extended Medicare benefits to cover the high cost of medical care for most individuals living from ESRD. 

The statutory mission of the Program, as set forth in Section 1862(g) of the Act, involves the Secretary entering into contracts with ESRD Networks for purposes of improving cost-effectiveness, ensuring quality of care, encouraging kidney transplantation and home dialysis, and increasing program accountability.



DESCRIPTION OF RESPONDENTS: 
This survey is intended to be completed by dialysis facilities who receive technical assistance and attend learning activities provided by the ESRD Network for the contract year beginning March 1, 2023. As of November 2022, there are 7,794 dialysis facilities.





TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form 	[X ] Customer Satisfaction Survey    
[ ] Usability Testing (e.g., Website or Software	[ ] Small Discussion Group
[ ]  Focus Group  					[ ] Other: ______________________		

CERTIFICATION:

I certify the following to be true: 
    1. The collection is voluntary. 
    2. The collection is low-burden for respondents and low-cost for the Federal Government.
    3. The collection is non-controversial and does not raise issues of concern to other federal agencies.									
    4. The results are not intended to be disseminated to the public.		
    5. Information gathered will not be used for the purpose of substantially informing influential policy decisions. 
    6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name: _Christina N. Goatee_______________________________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:
    1. Is personally identifiable information (PII) collected?  [  ] Yes  [X]  No 
    2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974?   [  ] Yes [  ] No   
    3. If Yes, has an up-to-date System of Records Notice (SORN) been published?  [  ] Yes  [  ] No

Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?  [  ] Yes [X] No  




BURDEN HOURS 

Category of Respondent
No. of Respondents
Participation Time
Burden
Private Sector (Dialysis facilities)
7,794
.033 hour
257 hours
Individual patients



Totals




FEDERAL COST:   The
ESRD Network employee salary and benefits who administers the survey
Time to Receive Form
Cost of FTE
Number of Networks
Estimated National  Cost
$100,000
.05 FTE
$5,000
18
$90,000
The cost is incorporated into the ESRD Network contracts for the 18 ESRD Networks in the program.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents
    1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe?											[X] Yes	[ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)?   If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

The satisfaction survey will be distributed broadly to ESRD dialysis facilities following learning and quality improvement activities. There is no sample delineated as DKH is determining the spread and effectiveness of the activities conducted by the ESRD Network program.




Administration of the Instrument
    1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media 
[  ] Telephone	
[  ] In-person	
[  ] Mail 
[  ] Other, Explain
    2. Will interviewers or facilitators be used?  [  ] Yes [X] No
 
Please make sure that all instruments, instructions, and scripts are submitted with the request.
Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” 

TITLE OF INFORMATION COLLECTION:  Provide the name of the collection that is the subject of the request. (e.g.  Comment card for soliciting feedback on xxxx)

PURPOSE:  Provide a brief description of the purpose of this collection and how it will be used.  If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information.  These groups must have experience with the program.

TYPE OF COLLECTION: Check one box.  If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION:  Please read the certification carefully.  If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information:  Provide answers to the questions.  Note:  Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments:  If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:
Category of Respondents:  Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government.  Only one type of respondent can be selected per row. 
No. of Respondents:  Provide an estimate of the Number of respondents.
Participation Time:  Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)
Burden:  Provide the Annual burden hours:  Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

If you are conducting a focus group, survey, or plan to employ statistical methods, please  provide answers to the following questions:

The selection of your targeted respondents.  Please provide a description of how you plan to identify your potential group of respondents and how you will select them.  If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument:  Identify how the information will be collected.  More than one box may be checked.  Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.