Information Collection

Medicare CAHPS Disenrollment Survey

IC 8534 under ICR 200006-0938-009 · OMB 0938-0779.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0779 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Medicare CAHPS Disenrollment Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

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	HCFA-R-295				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 112,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	90,240	18,240	72,000
Annual IC Time Burden (Hours)	39,744	15,984	23,760
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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