OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Beneficiary Satisfaction Survey

IC 208113 under ICR 201410-0938-001 · OMB 0938-1219.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Beneficiary Satisfaction Survey
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

3,561 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,561 0 0 0 0 3,561
Annual IC Time Burden (Hours) 1,000 0 0 0 0 1,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.