Information Collection

SHOP Satisfaction Surveys

IC 219294 under ICR 201512-0938-005 · OMB 0938-1303.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10555 SHOP Satisfaction Surveys	Form and Instruction
CMS-10555 SHOP Notices Agents-Brokers Survey CMS-10555 - Attachment 1 SHOP Notices Agents-Brokers Survey.docx	Form and Instruction
CMS-10555 SHOP Notices - Employer Survey CMS-10555 - Attachment 2 SHOP Notices Employer Survey.docx	Form and Instruction
CMS-10555 SHOP Notices - Employee Survey.docx CMS-10555 - Attachment 3 SHOP Notices Employee Survey.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10555	SHOP Notices Agents-Brokers Survey	CMS-10555 - Attachment 1 SHOP Notices Agents-Brokers Survey.docx	Yes	No	Fillable Fileable
Form and Instruction	CMS-10555	SHOP Notices - Employer Survey	CMS-10555 - Attachment 2 SHOP Notices Employer Survey.docx	Yes	No	Fillable Fileable
Form and Instruction	CMS-10555	SHOP Notices - Employee Survey.docx	CMS-10555 - Attachment 3 SHOP Notices Employee Survey.docx	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,440

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	4,880	4,880
Annual IC Time Burden (Hours)	2,440	2,440
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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