Information Collection

Parts C and D Complaints Resolution Performance Measures (CMS-10308)

IC 193233 under ICR 201307-0938-021 · OMB 0938-1107.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10308 Parts C and D Complaints Resolution Performance Measures (CMS-10308)	Form and Instruction
CMS-10308 Complaints Resolution Survey (Spanish) CROY2_WebBasedSurvey_SpanishScreenshots_130129.pdf	Form and Instruction
CMS-10308 Complaints Resolution Survey (English) CROY2_WebBasedSurvey_Screenshots_121218.pdf	Form and Instruction
6401 OMB Explanations for Inclusion of Survey Questions 100202.pdf Explaination of Survey Questions	IC Document
CROSSWALK - Changes to Advance Letter, Supporting Statements A and B, Survey Instrument, and Frequently Asked Questions.docx CROSSWALK - Changes to Advance Letter, Supporting Statements A and B, Survey Instrument, and Frequently Asked Questions	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-10308	Complaints Resolution Survey (Spanish)	CROY2_WebBasedSurvey_SpanishScreenshots_130129.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10308	Complaints Resolution Survey (English)	CROY2_WebBasedSurvey_Screenshots_121218.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59,032

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 97 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18,210	12,910	5,300
Annual IC Time Burden (Hours)	3,035	2,151	884
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Explaination of Survey Questions	6401 OMB Explanations for Inclusion of Survey Questions 100202.pdf	07/25/2013
CROSSWALK - Changes to Advance Letter, Supporting Statements A and B, Survey Instrument, and Frequently Asked Questions	CROSSWALK - Changes to Advance Letter, Supporting Statements A and B, Survey Instrument, and Frequently Asked Questions.docx	07/25/2013

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