Document
J.9 Customer Satisfaction Survey
ICR 202610-0938-001 · OMB 0938-1185 · Object 173821100.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | J.9 Customer Satisfaction Survey |
| Author | LISA REES |
| Last Modified By | Writer |
| File Modified | 2023-02-03 |
| File Created | 2026-10-15 |
| Conversion State | complete |
Extracted Text
NNetwork Name How Are We Doing? We are committed to providing patients and dialysis facility staff with the best assistance and learning opportunities possible, so we welcome your comments. Please provide us feedback so we can improve our service to the ESRD community. Thank you. Please rate the assistance and education received from the Network to decrease hospital admissions, hospital 30-day readmissions and emergency department visits. ¨¨ N/A ¨¨ 1 ¨¨ 2 ¨¨ 3 ¨¨ 4 ¨¨ 5 Dissatisfied Extremely Satisfied Please rate the assistance and education received from the Network to decrease the need for blood transfusions, hemodialysis access infections, and peritonitis for patients receiving dialysis in a nursing home. ¨¨ N/A ¨¨ 1 ¨¨ 2 ¨¨ 3 ¨¨ 4 ¨¨ 5 Dissatisfied Extremely Satisfied Please rate the assistance and education received from the Network to increase the use of a home modality. ¨¨ N/A ¨¨ 1 ¨¨ 2 ¨¨ 3 ¨¨ 4 ¨¨ 5 Dissatisfied Extremely Satisfied Please rate the assistance and education received from the Network to increase the use of telehealth/telemedicine. ¨¨ N/A ¨¨ 1 ¨¨ 2 ¨¨ 3 ¨¨ 4 ¨¨ 5 Dissatisfied Extremely Satisfied Please rate the assistance and education received from the Network to increase the number of patients that receive a transplant. ¨¨ N/A ¨¨ 1 ¨¨ 2 ¨¨ 3 ¨¨ 4 ¨¨ 5 Dissatisfied Extremely Satisfied Please rate the assistance and education received from the Network to increase patient involvement in care planning, QAPI, and peer mentoring. ¨¨ N/A ¨¨ 1 ¨¨ 2 ¨¨ 3 ¨¨ 4 ¨¨ 5 Dissatisfied Extremely Satisfied Please rate the customer service received from the Network during interactions. ¨¨ N/A ¨¨ 1 ¨¨ 2 ¨¨ 3 ¨¨ 4 ¨¨ 5 Dissatisfied Extremely Satisfied According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). This is a voluntary information collection. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Christina Goatee.