Information Collection

GenIC # 4: Web Intercept Survey of HealthCare.gov Visitors

IC 218875 under ICR 201307-0938-017 · OMB 0938-1247.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10437-GenIC#4 GenIC # 4: Web Intercept Survey of HealthCare.gov Visitors	Form and Instruction
CMS-10437-GenIC#4 Web Intercept Survey of HealthCare.gov Visitors CMS-10437#4 -Instrument with disclosure statement.pdf	Form and Instruction
CMS-10437. GenIC#4 -Mini Supporting Statement.docx CMS-10437. GenIC#4 -Mini Supporting Statement	IC Document

IC Title:

GenIC # 4: Web Intercept Survey of HealthCare.gov Visitors

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-10437-GenIC#4	Web Intercept Survey of HealthCare.gov Visitors	CMS-10437#4 -Instrument with disclosure statement.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	14,000	14,000
Annual IC Time Burden (Hours)	933	933
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10437. GenIC#4 -Mini Supporting Statement	CMS-10437. GenIC#4 -Mini Supporting Statement.docx	11/04/2015

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