Information Collection

Beneficiary Satisfaction Survey

IC 208113 under ICR 201308-0938-006 · OMB 0938-1219.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1219 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10477 Beneficiary Satisfaction Survey	Form and Instruction
CMS-10477 Beneficiary survey questionnaire Attachment_6c_Survey_English_clean.docx	Form and Instruction
CMS-10477 Beneficiary survey phone follow-up for non-responders Attachment_6e_Survey_Telephone_Follow-up_Script_English_clean.docx	Form and Instruction
CMS-10477 CATI_Script_Spanish_new_clean Attachment_9e_CATI_Script_Spanish_new_clean.docx	Form and Instruction
CMS-10477 Survey_Spanish_new_clean Attachment_9c_Survey_Spanish_new_clean.doc	Form and Instruction
Attachment_6a_Prenotification_Letter_English_clean.docx Beneficiary survey pre-notification letter	IC Document
Attachment_6b_Survey_Cover_Letter_English_clean.docx Beneficiary survey mail cover letter	IC Document
Attachment_6d_Reminder_Letter_English_clean.docx Beneficiary survey reminder letter	IC Document
Attachment_9a_Prenotification_Letter_Spanish_new_clean.docx Attachment_9a_Prenotification_Letter_Spanish_new_clean	IC Document
Attachment_9b_Survey_Cover_Letter_Spanish_clean.docx Attachment_9b_Survey_Cover_Letter_Spanish_clean	IC Document
Attachment_9d_Reminder_Letter_Spanish_new_clean.docx Attachment_9d_Reminder_Letter_Spanish_new_clean	IC Document

IC Title:

Beneficiary Satisfaction Survey

Agency IC Tracking Number:

Is this a Common Form? No

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10477	CATI_Script_Spanish_new_clean	Attachment_9e_CATI_Script_Spanish_new_clean.docx	No		Fillable Fileable
Form and Instruction	CMS-10477	Survey_Spanish_new_clean	Attachment_9c_Survey_Spanish_new_clean.doc	No		Fillable Fileable
Form and Instruction	CMS-10477	Beneficiary survey questionnaire	Attachment_6c_Survey_English_clean.docx	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Beneficiary survey phone follow-up for non-responders	Attachment_6e_Survey_Telephone_Follow-up_Script_English_clean.docx	No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,561

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,561	3,561
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Beneficiary survey pre-notification letter	Attachment_6a_Prenotification_Letter_English_clean.docx	01/15/2014
Beneficiary survey mail cover letter	Attachment_6b_Survey_Cover_Letter_English_clean.docx	01/15/2014
Beneficiary survey reminder letter	Attachment_6d_Reminder_Letter_English_clean.docx	01/15/2014
Attachment_9a_Prenotification_Letter_Spanish_new_clean	Attachment_9a_Prenotification_Letter_Spanish_new_clean.docx	01/15/2014
Attachment_9b_Survey_Cover_Letter_Spanish_clean	Attachment_9b_Survey_Cover_Letter_Spanish_clean.docx	01/15/2014
Attachment_9d_Reminder_Letter_Spanish_new_clean	Attachment_9d_Reminder_Letter_Spanish_new_clean.docx	01/15/2014

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