1-800 MEDICARE Beneficiary Satisfaction Survey (Outbound Telephone Survey)

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail

This template is intended for staff without an ICRAS account. Please fill out and submit to the appropriate Operating Division to enter into ICRAS. The form mirrors the screens available in the ICRAS 4 system. To request an account to log into ICRAS.

Instructions for filling out the form are available at www.paperworkreduction.gov.

Title 1-800 MEDICARE Beneficiary Satisfaction Survey (Outbound Telephone Survey)

Is this a Common Form?

Obligation to respond (check one)

Frequency of reporting (check all that apply)

Yes

No

a. Voluntary

b. Required to obtain or retain benefits

c. Mandatory

a. Hourly (24 -7)

b. Hourly Bus (40 per week)

c. Daily (7 per week)

d. Daily Bus (5 per week)

e. Weekly (52 per year)

f. Monthly

g. Yearly

h. Every Decade

i. Quarterly

j. Semi-annually

k. Biennially

l. Once

m. occasionally

CFR Citation(s) for the information collection under review (if applicable).

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Information Collection Instruments – Send all instruments along with the Part 2 form(s). If more than one Part 2 is completed make sure to identify which instruments are associated with which Part 2 form. Phone Script Attached.

Federal Enterprise Architecture Business Reference Model (Select one Services for Citizens Line of Business and one Subfunction from its group)

Table 1. Federal Enterprise Architecture Business Reference Model

Services for Citizens Line of Business	Subfunction
None
Community and Social Services	Homeownership Promotion Community and Regional Development Social Services Postal Service None
Correctional Activities	Criminal Incarceration Criminal Rehabilitation None
Defense and National Security	Strategic National and Theater Defense Operational Defense Tactical Defense None
Disaster Management	Disaster Monitoring and Predication Disaster Preparedness and Planning Disaster Repair and Restore Emergency Response None
Economic Development	Business and Industry Development Intellectual Property Protection Financial Sector Oversight Industry Sector Income Stabilization None
Education	Elementary, Secondary, and Vocational Education Higher Education Cultural and Historic Preservation Cultural and Historic Exhibition None
Energy	Energy Supply Energy Conservation and Preparedness Energy Resource Management Energy Production None
Environmental Management	Environmental Monitoring and Forecasting Environmental Remediation Pollution Prevention and Control None
General Science and Innovation	Scientific and Technological Research and Innovation Space Exploration and Innovation None
Health	Illness Prevention Immunization Management Public Health Monitoring Health Care Services Consumer Health and Safety None
Homeland Security	Border and Transportation Security Key Asset and Critical Infrastructure Protection Catastrophic Defense None
Income Security	General Retirement and Disability Unemployment Compensation Housing Assistance Food and Nutrition Assistance Survivor Compensation None
Intelligence Operations	Intelligence Planning and Direction/Needs Intelligence Collection Intelligence Analysis and Production Dissemination None
International Affairs and Commerce	Foreign Affairs International Development and Humanitarian Aid Global Trade None
Law Enforcement	Criminal Apprehension Criminal Investigation and Surveillance Citizen Protection Crime Prevention Leadership Protection Property Protection Substance Control None
Litigation and Judicial Activities	Judicial Hearing Legal Defense Legal Investigation Legal Prosecution and Litigation Resolution Facilitation None
Natural Resources	Water Resource Management Conservation, Marine and Land Management Recreational Resource Management and Tourism Agricultural Innovation and Services None
Transportation	Air Transportation Ground Transportation Water Transportation Space Operations None
Workforce Management	Training and Employment Labor Rights Management Worker Safety None

Table 1 lists Services for Citizens Line of Business and Subfunctions

See http://www.feapmo.gov for the Business Reference Model categories and definitions.

Privacy Act System of Records (if applicable)

Title:     

Federal Register Citation: Volume       Page number       Publication date      /     /     

Respondents

a. Total # 14700

b. Small Entity #      

c. Percent Electronic 100%

Affected public (choose one)
a. Individuals or households

b. Private Sector
c. State, Local, or Tribal Governments
d. Federal Government

(if Private Sector check all that apply)
a. Business or other for-profits
b. Not-for-profit institutions
c. Farms

Frequency: How often on average will each respondent respond to the Information Collection?

Number of Responses per Respondent 1

Per (select the most appropriate time period for this collection)

a. Hour (24-7) - 8736 per year

b. Business Hour (40 per week) - 2080 per year

c. Day (7 per week) - 364 per year

d. Business Day (5 per week) - 260 per year

e. Week - 52 per year

f. Month - 12 per year

g. Year

h. Decade .1 per year

i. Quarter - 4 per year

j. Half-Year - 2 per year

k. Biennial - 0.5 per year

Calculated: Annual Frequency =1 times a year (per respondent)

Calculated: Annual Number Of Responses = 14700 a year

Hour and Cost Burden Enter the hours and cost (per response) broken out by reporting, record keeping, and third-party disclosure. Table 2. Hours and Cost per response
	Time per Response	Hour per response	Annual Hour Burden	Cost per Response	Annual cost Burden
Reporting	11 mins	.1826	2684.22
Record keeping
Third party disclosure	     	     	     	     	     
Total	11 mins	.1826	2684.22
Table 2 lists hours and cost

Allocate the change in burden

Table 3 Change in Burden

	Total Requested	Change Due to New Statute	Change Due to Agency Discretion	Due to Agency Estimate	Change Due Violation	Currently Approved
a. Annual Responses	14,700	     	1668	     	     	13,032
b. Annual Hour Burden	2684.22hours	      hours	1055.22hours	      hours	      hours	1,629 hours
c. Annual Cost Burden		$      	$      	$      	$      	$      

Table 3 lists Change in Burden numbers