Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form GenIC #5 End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)	Form and Instruction	New	Available
Form CMS-10534 Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project	Form and Instruction	New	Available
Form CMS-10533 Usability Testing for the Health Insurance Marketplace Websites: Health Insurance Marketplave Consumer Experiernce Surveys Project	Form and Instruction	New	Available
Form 0938-1185 Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	Form and Instruction	New	Repair queued
Form CMS-10415 Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction	New	Available
Generic Clearance Submission Template.doc	Supplementary Document	Uploaded 2012-12-13	Available
CMS-10415.Supporting Statement Part B.DOC	Supporting Statement B	Uploaded 2012-09-13	Available
CMS-10415.Revised Supporting Statement Part A (8-20-12).DOCX	Supporting Statement A	Uploaded 2012-09-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214103	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)	Form and Instruction	New
212695	Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project	Form and Instruction	New
212692	Usability Testing for the Health Insurance Marketplace Websites: Health Insurance Marketplave Consumer Experiernce Surveys Project	Form and Instruction	New
208331	Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	Form and Instruction	New
207445	Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction	New

ICR Details

OMB Control No: 0938-1185	ICR Reference No: 201210-0938-003
Status: Historical Active	Previous ICR Reference No: 201206-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/21/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/01/2012
Terms of Clearance: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved
Responses	1,000,000	0	0
Time Burden (Hours)	25,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the agency's programs. This feedback will provide insights into customer or stakeholder perceptions, experiences and expectations, provide an early warning of issues with service, or focus attention on areas where communication, training or changes in operations might improve delivery of products or services. These collections will allow for ongoing, collaborative and actionable communications between the Agency and its customers and stakeholders. It will also allow feedback to contribute directly to the improvement of program management.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
EO: EO 13571 Name/Subject of EO: Streamlining Service Delivery and Improving Customer Service

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 80542	12/22/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 31616	05/29/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Beneficiary Contact Center Customer Satisfaction Survey	CMS-10415	IVR Phone Script for Survey
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)	GenIC #5	ESRD Grievant Satisfaction Survey
Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	0938-1185	Stakeholder Training Forms
Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project	CMS-10534	Cognitive Interview Guide, Screener and Consent Forms
Usability Testing for the Health Insurance Marketplace Websites: Health Insurance Marketplave Consumer Experiernce Surveys Project	CMS-10533	Consumer Usability Testing Guide, and Screeners

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000,000	0	1,000,000	0	0	0
Annual Time Burden (Hours)	25,000	0	25,000	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $217,200

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/01/2012

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