Information Collection

Medicare Beneficiary and Family-Centered Satisfaction Survey

IC 201543 under ICR 201204-0938-001 · OMB 0938-1177.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1177 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10393 Medicare Beneficiary and Family-Centered Satisfaction Survey	Form
CMS-10393 Bene Survey Appeals Bene Survey Appeals (SP) - v1 51512.pdf	Form
CMS-10393 Bene Survey Complaint Bene Survey Complaint (SP) - v1 51512.pdf	Form
CMS Medicare Beneficiary Survey Revision Crosswalk 022912.docx Crosswalk	IC Document

IC Title:

Medicare Beneficiary and Family-Centered Satisfaction 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	CMS-10393	Bene Survey Appeals	Bene Survey Appeals (SP) - v1 51512.pdf		No		Paper Only
Form	CMS-10393	Bene Survey Complaint	Bene Survey Complaint (SP) - v1 51512.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 68,000

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	68,000	68,000
Annual IC Time Burden (Hours)	17,000	17,000
Annual IC Cost Burden (Dollars)	85,000	85,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS Medicare Beneficiary Survey Revision Crosswalk 022912.docx	03/27/2012

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