GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398 (#44) GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool Form and Instruction
CMS-10398 (#44) Customer Satisfaction Evaluation of Form CMS-416 Web-Bas 44 - CMS-416 Curriculum Evaluation [rev 09-17-2015 by OSORA PRA] -- CLEAN.docx Form and Instruction
44 - Supporting Statement Oral Health Initiative Tool [rev 09-17-2015 by OSORA PRA] -- CLEAN.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #44 - Oral Health Initiative, Customer Satisfaction Survey Tool	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 (#44)	Customer Satisfaction Evaluation of Form CMS-416 Web-Based Training Modules	44 - CMS-416 Curriculum Evaluation [rev 09-17-2015 by OSORA PRA] -- CLEAN.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	44 - Supporting Statement Oral Health Initiative Tool [rev 09-17-2015 by OSORA PRA] -- CLEAN.docx	09/18/2015

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