Information Collection

Beneficiary Contact Center Customer Satisfaction Survey

IC 207445 under ICR 201210-0938-003 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10415 Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction
CMS-10415 IVR Phone Script for Survey OMB IVR Phone Script 2013.docx	Form and Instruction
BCC Satisfaction Survey Submission form.doc BCC Satisfaction Survey Submission form	IC Document

IC Title:

Beneficiary Contact Center Customer Satisfaction Survey

Agency IC Tracking Number:

IC Status: New

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-10415	IVR Phone Script for Survey	OMB IVR Phone Script 2013.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 145,000

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	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	145,000	0	0	0	0	0
Annual IC Time Burden (Hours)	5,776	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
BCC Satisfaction Survey Submission form	BCC Satisfaction Survey Submission form.doc	06/18/2013

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