Information Collection

Medicare Disenrollment Survey - Stand Alone PDP Version (CMS-10316)

IC 194737 under ICR 201307-0938-003 · OMB 0938-1113.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1113 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10316 Medicare Disenrollment Survey - Stand Alone PDP Version (CMS-10316) Form
CMS-10316 Medicare Disenrollee Survey: Prescription Drug Plan Attachment 4 - PDP Survey.docx Form
Attachment 1 - PRE NOTIFICATION LETTERS.docx Attachment 1 - PRE NOTIFICATION LETTERS IC Document
Attachment 2 - SURVEY COVER LETTERS.docx Attachment 2 - SURVEY COVER LETTERS IC Document
Crosswalk - PDP.xlsx Crosswalk - PDP IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Disenrollment Survey - Stand Alone PDP Version (CMS-10316)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.156

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10316	Medicare Disenrollee Survey: Prescription Drug Plan	Attachment 4 - PDP Survey.docx		No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39,582	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	19,791	-40,209	60,000
Annual IC Time Burden (Hours)	4,750	-12,050	16,800
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 1 - PRE NOTIFICATION LETTERS	Attachment 1 - PRE NOTIFICATION LETTERS.docx	07/08/2013
Attachment 2 - SURVEY COVER LETTERS	Attachment 2 - SURVEY COVER LETTERS.docx	07/08/2013
Crosswalk - PDP	Crosswalk - PDP.xlsx	07/08/2013

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