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

Forms and Documents

Document Name	Status
Form GenIC#5 End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2 Form and Instruction	New
Form CMS-10590 (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
Form CMS-10591 (CMS-10591) Cognitive Testing for the Marketplace Dental Survey Form and Instruction	New
Form CMS-10588 (CMS-10588) Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project Form and Instruction	New
Form CMS-10585 (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
Form CMS-10584 Health Care Payment Learning and Action Network Registration (CMS-10584) Form and Instruction	New
Form CMS-10562 Quality Reporting Process Survey (CMS-10562) Form and Instruction	Unchanged
Form CMS-10557 Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557) Form	Unchanged
Form CMS-10560 (CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey Form and Instruction	Unchanged
Form CMS-10559 Health Care Payment Learning and Action Network (CMS-10559) Form and Instruction	Unchanged
Form CMS-10557 Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557) Form	Unchanged
Form Beneficiary Teleph 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
Form CMS-10546 (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
Form GenIC #5 End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) Form and Instruction	Modified
Form CMS-10534 Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project Form and Instruction	Unchanged
Form CMS-10533 Usability Testing for the Health Insurance Marketplace Websites: Health Insurance Marketplave Consumer Experiernce Surveys Project Form and Instruction	Unchanged
Form 0938-1185 Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs Form and Instruction	Unchanged
Form CMS-10415 Beneficiary Contact Center Customer Satisfaction Survey Form and Instruction	Unchanged
0938-1185 Change Justification_ESRD Grievant Satisfaction Survey (6-2015).pdf Justification for No Material/Nonsubstantive Change	2015-06-26
0938-1185 - Justification of Nonsub Change Request.docx Justification for No Material/Nonsubstantive Change	2014-12-17
Generic Clearance Submission Template.doc Supplementary Document	2012-12-13
CMS-10415.Supporting Statement Part B.DOC Supporting Statement B	2012-09-13
CMS-10415.Revised Supporting Statement Part A (8-20-12).DOCX Supporting Statement A	2012-09-13

IC Document Collections

IC ID	Document Title	Status
219259	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2 Form and Instruction	New
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
218995	(CMS-10591) Cognitive Testing for the Marketplace Dental Survey Form and Instruction	New
218801	(CMS-10588) Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project Form and Instruction	New
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
218155	Health Care Payment Learning and Action Network Registration (CMS-10584) Form and Instruction	New
216841	Peer Coach Assessment Instruction	Unchanged
216680	Quality Reporting Process Survey (CMS-10562) Form and Instruction	Unchanged
216383	Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557) Form	Unchanged
216236	(CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey Form and Instruction	Unchanged
215761	Health Care Payment Learning and Action Network (CMS-10559) Form and Instruction	Unchanged
215707	Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557) Form	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
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
214103	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) Form and Instruction	Modified
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
212692	Usability Testing for the Health Insurance Marketplace Websites: Health Insurance Marketplave Consumer Experiernce Surveys Project Form and Instruction	Unchanged
208331	Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs Form and Instruction	Unchanged
207445	Beneficiary Contact Center Customer Satisfaction Survey Form and Instruction	Unchanged

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
	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.

	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

IC Title	Form No.	Form Name
Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	0938-1185	Stakeholder Training Forms
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
Quality Reporting Process Survey (CMS-10562)	CMS-10562	Quality Reporting Process Survey
(CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey	CMS-10560	Focus Group Eligibility Screener, Consent form and Protocol
(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
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
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
(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
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)	GenIC #5	ESRD Grievant
(CMS-10591) Cognitive Testing for the Marketplace Dental Survey	CMS-10591	Marketplace Dental Survey Cognitive Testing Eligibility Screener
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
Peer Coach Assessment
(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
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
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2	GenIC#5	ESRD Greivant Satisfaction Survey
Beneficiary Contact Center Customer Satisfaction Survey	CMS-10415	IVR Phone Script for 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

	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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