Information Collection

English - Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 201402-0938-007 · OMB 0938-1221.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1221 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10488 English - Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
CMS-10488 English - Adult Qualified Health Plan Enrollee Experienc English Adult QHP Enrollee Experience Survey after OMB NCHS review_clean_2-5-14_CMS.docx	Form and Instruction

IC Title:

English - Adult Qualified Health Plan Enrollee Experience Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 156.200(b)(5) 45 CFR 155.200(d)

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-10488	English - Adult Qualified Health Plan Enrollee Experience Survey	English Adult QHP Enrollee Experience Survey after OMB NCHS review_clean_2-5-14_CMS.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 604,240

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: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	604,240	604,240
Annual IC Time Burden (Hours)	271,930	271,930
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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