Information Collection

Beneficiary Customer Service Feedback Survey

IC 37921 under ICR 201009-0938-007 · OMB 0938-0894.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0894 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10068 Beneficiary Customer Service Feedback Survey	Form and Instruction
CMS-10068 Beneficiary Customer Service Feedback Survey Bene Survey-English 2010 (NEW)(Plain Lang) 4-14-10.doc	Form and Instruction

IC Title:

Beneficiary Customer Service Feedback Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10068	Beneficiary Customer Service Feedback Survey	Bene Survey-English 2010 (NEW)(Plain Lang) 4-14-10.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,242

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,242	2,242
Annual IC Time Burden (Hours)	224	224
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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