Beneficiary Satisfaction Survey

Medicaid Incentives for Prevention of Chronic Diseases Evaluation (CMS-10477)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Beneficiary Satisfaction Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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
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

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
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

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.