GenIC#5 - Consumer Survey of Marketplace Disenrollees

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⚠️ Notice: This information collection may be referencing outdated material.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#5 - Consumer Survey of Marketplace Disenrollees Form and Instruction
CMS-10437 Consumer Survey of Marketplace Disenrollees CMS-10437.GenIC#5 - Disenrollee Survey Instrument with Disclosure Statement.docx Form and Instruction
CMS-10437.GenIC #5 - Application to Use Burden hours -Consumer Survey of Marketplace Disenrollees.docx CMS-10437.GenIC #5 - Application to Use Burden hours -Consumer Survey of Marketplace Disenrollees IC Document

Information Collection (IC) Details

IC Title:	GenIC#5 - Consumer Survey of Marketplace Disenrollees	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	Consumer Survey of Marketplace Disenrollees	CMS-10437.GenIC#5 - Disenrollee Survey Instrument with Disclosure Statement.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	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
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10437.GenIC #5 - Application to Use Burden hours -Consumer Survey of Marketplace Disenrollees	CMS-10437.GenIC #5 - Application to Use Burden hours -Consumer Survey of Marketplace Disenrollees.docx	02/04/2016

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