Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form GenIC#5 ESRD Greivant Satisfaction Survey	Form and Instruction	New	Available
Form CMS-10396 Telephone Interview Script	Form and Instruction	New	Available
Form CMS-10590 Quality Net User Survey	Form and Instruction	New	Available
Form CMS-10591 Marketplace Dental Survey Cognitive Testing Eligibility Screener	Form and Instruction	New	Available
Form CMS-10588 Usability Test Script	Form and Instruction	New	Available
Form CMS-10585 Quality Net User Survey	Form and Instruction	New	Available
Form CMS-10584 LAN Summit Registration Form	Form and Instruction	New	Available
Form CMS-10562 Quality Reporting Process Survey	Form and Instruction	Unchanged	Available
Form CMS-10557 Pilot Test Registration Tool	Form	Unchanged	Available
Form CMS-10560 Focus Group Eligibility Screener, Consent form and Protocol	Form and Instruction	Unchanged	Available
Form CMS-10559 Health Care Payment Learning and Action Network	Form and Instruction	Unchanged	Available
Form CMS-10557 PACE Pilot Test Evaluation	Form	Unchanged	Available
Form Beneficiary Teleph CMS-10396	Form and Instruction	Unchanged	Available
Form CMS-10546 Utilization of Health Information Technology in Post-Acute Care Settings	Form and Instruction	Unchanged	Available
Form GenIC #5 ESRD Grievant	Form and Instruction	Modified	Available
Form CMS-10534 Cognitive Interview Guide, Screener and Consent Forms	Form and Instruction	Unchanged	Available
Form CMS-10533 Consumer Usability Testing Guide, and Screeners	Form and Instruction	Unchanged	Available
Form 0938-1185 Stakeholder Training Forms	Form and Instruction	Unchanged	Available
Form CMS-10415 IVR Phone Script for Survey	Form and Instruction	Unchanged	Available
0938-1185 Change Justification_ESRD Grievant Satisfaction Survey (6-2015).pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2015-06-26	Available
0938-1185 - Justification of Nonsub Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-12-17	Available
Generic Clearance Submission Template.doc	Supplementary Document	Uploaded 2012-12-13	Available
CMS-10415.Supporting Statement Part B.DOC	Supporting Statement B	Uploaded 2012-09-13	Available
CMS-10415.Revised Supporting Statement Part A (8-20-12).DOCX	Supporting Statement A	Uploaded 2012-09-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
219259	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2	Form and Instruction	New	ESRD Greivant Satisfaction Survey
219253	Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396)	Form and Instruction	New	Telephone Interview Script
219253	Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396)	Other-Beneficiary Solicitation Letter	New
219033	(CMS-10590) QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project.	Form and Instruction	New	Quality Net User Survey
218995	(CMS-10591) Cognitive Testing for the Marketplace Dental Survey	Form and Instruction	New	Marketplace Dental Survey Cognitive Testing Eligibility Screener
218801	(CMS-10588) Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project	Form and Instruction	New	Usability Test Script
218334	(CMS-10585) QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project	Form and Instruction	New	Quality Net User Survey
218155	Health Care Payment Learning and Action Network Registration (CMS-10584)	Form and Instruction	New	LAN Summit Registration Form
216841	Peer Coach Assessment	Instruction	Unchanged
216680	Quality Reporting Process Survey (CMS-10562)	Form and Instruction	Unchanged	Quality Reporting Process Survey
216383	Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557)	Form	Unchanged	Pilot Test Registration Tool
216236	(CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey	Form and Instruction	Unchanged	Focus Group Eligibility Screener, Consent form and Protocol
215761	Health Care Payment Learning and Action Network (CMS-10559)	Form and Instruction	Unchanged	Health Care Payment Learning and Action Network
215707	Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557)	Form	Unchanged	PACE Pilot Test Evaluation
215707	Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557)	Other-Recruitment Reminder Letter	Unchanged
214725	Instrument for Soliciting Feedback on Satisfaction With, and Changes to, the Standardized Format (Medication Therapy Management Program Improvements; CMS-10396, OMB No. 0938-1154) (GenIC#6)	Form and Instruction	Unchanged	CMS-10396
214725	Instrument for Soliciting Feedback on Satisfaction With, and Changes to, the Standardized Format (Medication Therapy Management Program Improvements; CMS-10396, OMB No. 0938-1154) (GenIC#6)	Other-Medicare Beneficiary Mailed Solicitation Letter	Unchanged
214407	(CMS-10546) Survey for Long-Term (LT) and Post-Acute Care (PAC) Electronic Health Records (EHR) and Health Information Exchange (HIE) Adoption	Form and Instruction	Unchanged	Utilization of Health Information Technology in Post-Acute Care Settings
214103	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)	Form and Instruction	Modified	ESRD Grievant
212695	Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project	Form and Instruction	Unchanged	Cognitive Interview Guide, Screener and Consent Forms
212692	Usability Testing for the Health Insurance Marketplace Websites: Health Insurance Marketplave Consumer Experiernce Surveys Project	Form and Instruction	Unchanged	Consumer Usability Testing Guide, and Screeners
208331	Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	Form and Instruction	Unchanged	Stakeholder Training Forms
207445	Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction	Unchanged	IVR Phone Script for Survey

ICR Details

OMB Control No: 0938-1185	ICR Reference No: 201506-0938-013
Status: Historical Active	Previous ICR Reference No: 201412-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/30/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/26/2015
Terms of Clearance: Previous terms continue: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	12/31/2015	12/31/2015
Responses	1,000,000	0	1,000,000
Time Burden (Hours)	25,000	0	25,000
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the agency's programs. This feedback will provide insights into customer or stakeholder perceptions, experiences and expectations, provide an early warning of issues with service, or focus attention on areas where communication, training or changes in operations might improve delivery of products or services. These collections will allow for ongoing, collaborative and actionable communications between the Agency and its customers and stakeholders. It will also allow feedback to contribute directly to the improvement of program management.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
EO: EO 13571 Name/Subject of EO: Streamlining Service Delivery and Improving Customer Service

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 80542	12/22/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 31616	05/29/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 20

table that charts list of burden

IC Title	Form No.	Form Name
(CMS-10546) Survey for Long-Term (LT) and Post-Acute Care (PAC) Electronic Health Records (EHR) and Health Information Exchange (HIE) Adoption	CMS-10546	Utilization of Health Information Technology in Post-Acute Care Settings
(CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey	CMS-10560	Focus Group Eligibility Screener, Consent form and Protocol
(CMS-10585) QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project	CMS-10585	Quality Net User Survey
(CMS-10588) Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project	CMS-10588	Usability Test Script
(CMS-10590) QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project.	CMS-10590	Quality Net User Survey
(CMS-10591) Cognitive Testing for the Marketplace Dental Survey	CMS-10591	Marketplace Dental Survey Cognitive Testing Eligibility Screener
Beneficiary Contact Center Customer Satisfaction Survey	CMS-10415	IVR Phone Script for Survey
Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557)	CMS-10557	PACE Pilot Test Evaluation
Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557)	CMS-10557	Pilot Test Registration Tool
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)	GenIC #5	ESRD Grievant
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2	GenIC#5	ESRD Greivant Satisfaction Survey
Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	0938-1185	Stakeholder Training Forms
Health Care Payment Learning and Action Network (CMS-10559)	CMS-10559	Health Care Payment Learning and Action Network
Health Care Payment Learning and Action Network Registration (CMS-10584)	CMS-10584	LAN Summit Registration Form
Instrument for Soliciting Feedback on Satisfaction With, and Changes to, the Standardized Format (Medication Therapy Management Program Improvements; CMS-10396, OMB No. 0938-1154) (GenIC#6)	Beneficiary Telephone Interview Script	CMS-10396
Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396)	CMS-10396	Telephone Interview Script
Peer Coach Assessment
Quality Reporting Process Survey (CMS-10562)	CMS-10562	Quality Reporting Process Survey
Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project	CMS-10534	Cognitive Interview Guide, Screener and Consent Forms
Usability Testing for the Health Insurance Marketplace Websites: Health Insurance Marketplave Consumer Experiernce Surveys Project	CMS-10533	Consumer Usability Testing Guide, and Screeners

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000,000	1,000,000	0	0	0	0
Annual Time Burden (Hours)	25,000	25,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $217,200

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/26/2015

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