Information Collection

GenIC#14 - Medicare Beneficiary Consumer Survey

IC 227110 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⚠️ Notice: This information collection may be referencing outdated material.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# GenIC#14 - Medicare Beneficiary Consumer Survey	Form and Instruction
CMS-10437 - GenIC# Medicare Beneficiary Consumer Survey CMS-10437.GenIC14_Medicare Beneficiary Consumer Survey_Instrument.docx	Form and Instruction
CMS-10437. GenIC#14_Medicare Beneficiary Consumer Survey_SupportingStatement.docx CMS-10437. GenIC#14_Medicare Beneficiary Consumer Survey_SupportingStatement	IC Document
CMS-10437.GenIC14_Medicare Beneficiary Consumer Survey_CoverPage.docx CMS-10437.GenIC14_Medicare Beneficiary Consumer Survey_CoverPage	IC Document

IC Title:

GenIC#14 - Medicare Beneficiary Consumer 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-10437 - GenIC#14	Medicare Beneficiary Consumer Survey	CMS-10437.GenIC14_Medicare Beneficiary Consumer Survey_Instrument.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,800

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 Agency Discretion
Annual Number of Responses for this IC	4,800	4,800
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10437. GenIC#14_Medicare Beneficiary Consumer Survey_SupportingStatement	CMS-10437. GenIC#14_Medicare Beneficiary Consumer Survey_SupportingStatement.docx	06/06/2017
CMS-10437.GenIC14_Medicare Beneficiary Consumer Survey_CoverPage	CMS-10437.GenIC14_Medicare Beneficiary Consumer Survey_CoverPage.docx	06/06/2017

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