Medicare Ombudsman Customer Service Feedback Survey (CMS-10068)

Forms and Documents

Document Name	Status
Form CMS-10068 MEDICARE OMBUDSMAN CUSTOMER SERVICE FEEDBACK SURVEY Form and Instruction	Modified
CMS-10068 (0938-0894) Survey 2016 Crosswalk.docx Supplementary Document	2015-12-08
CMS-10068 (0938-0894) Non-SubstantiveChangeRequest (Dec 2015).docx Justification for No Material/Nonsubstantive Change	2015-12-08
CMS-10068ResponsetoPublicComments.docx Supplementary Document	2014-10-27
Survey 2014 Crosswalk - 5-20-14.docx Supplementary Document	2014-10-27
CMS-10068SupportingStatement-PartB.pdf Supporting Statement B	2014-10-27
CMS-10068SupportingStatement-PartA.docx Supporting Statement A	2014-10-27

IC Document Collections

IC ID	Document Title	Status
37921	MEDICARE OMBUDSMAN CUSTOMER SERVICE FEEDBACK SURVEY Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0894	ICR Reference No: 201512-0938-002
Status: Historical Active	Previous ICR Reference No: 201410-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Ombudsman Customer Service Feedback Survey (CMS-10068)
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: 04/28/2016
	Date Received in OIRA: 12/09/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2017	11/30/2017	11/30/2017
Responses	2,380	0	2,380
Time Burden (Hours)	317	0	317
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare and Medicaid Services stresses a continuing need for setting customer service goals that include providing accurate, timely, and relevant information to its customers. With these goals in mind, we periodically survey our customers to ensure that the needs of Medicare beneficiaries are being met. This survey will be used to measure overall satisfaction of the customer service that the Medicare Ombudsman Group (MOG) within CMS provides to Medicare beneficiaries and their representatives. The information provided will be used by management and staff to measure and improve the quality and timeliness of responses to written and verbal correspondence.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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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:
	79 FR 32963	06/09/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 56379	09/19/2014
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
MEDICARE OMBUDSMAN CUSTOMER SERVICE FEEDBACK SURVEY	CMS-10068	Medicare Ombudsman Customer Service Feedback Survey

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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	2,380	2,380	0	0	0	0
Annual Time Burden (Hours)	317	317	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: $9,139

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: 12/09/2015

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