GenIC#2 - 2015 Online Provider Assessment Survey

Generic Social Marketing & Consumer Testing Research

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1247 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10437: GenIC#2 GenIC#2 - 2015 Online Provider Assessment Survey Form and Instruction
CMS-10437: GenIC#2 2015 Online Provider Assessment Survey CMS-10437 GenIC#2 Instrument -2015 Online Provider Survey.docx Form and Instruction
CMS-10437 GenIC #2 - Incentive Justification.docx GneIC #2 - Incentive Justification IC Document
CMS-10437 GenIC#2 - Supp. State. 2015 Online Provider Survey.docx CMS-10437 GenIC#2 - Supp. State. 2015 Online Provider Survey IC Document

Information Collection (IC) Details

IC Title:	GenIC#2 - 2015 Online Provider Assessment Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10437: GenIC#2	2015 Online Provider Assessment Survey	CMS-10437 GenIC#2 Instrument -2015 Online Provider Survey.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	360	360
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GneIC #2 - Incentive Justification	CMS-10437 GenIC #2 - Incentive Justification.docx	07/29/2015
CMS-10437 GenIC#2 - Supp. State. 2015 Online Provider Survey	CMS-10437 GenIC#2 - Supp. State. 2015 Online Provider Survey.docx	07/29/2015

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