Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form GenIC#5 ESRD Greivant Satisfaction Survey Version 2.0	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-10534 Cognitive Interview Guide, Screener and Consent Forms	Form and Instruction	New	Available
Form CMS-10415 Stakeholder Training Forms	Form and Instruction	New	Available
Form CMS-10415 IVR Phone Script for Survey	Form and Instruction	New	Available
CMS-10415_Supporting_Statement_Part_B.doc	Supporting Statement B	Uploaded 2015-12-29	Available
CMS-10415_Supporting_Statement_Part_A (4-4-16).docx	Supporting Statement A	Uploaded 2016-04-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
219438	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2	Form and Instruction	New	ESRD Greivant Satisfaction Survey Version 2.0
219437	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
219437	Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396)	Other-Other-Visual Aid #2 ? Medication Action Plan Mockup	New
219436	QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590)	Form and Instruction	New	Quality Net User Survey
219435	Cognitive Testing for the Marketplace Dental Survey (CMS-10591)	Form and Instruction	New	Marketplace Dental Survey Cognitive Testing Eligibility Screener
219434	Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588)	Form and Instruction	New	Usability Test Script
219433	Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project (CMS-10534)	Form and Instruction	New	Cognitive Interview Guide, Screener and Consent Forms
219432	Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	Form and Instruction	New	Stakeholder Training Forms
219431	Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction	New	IVR Phone Script for Survey

ICR Details

OMB Control No: 0938-1185	ICR Reference No: 201512-0938-013
Status: Historical Active	Previous ICR Reference No: 201506-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/06/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/30/2015
Terms of Clearance: To request approval of individual information collections under this generic approval, the agency must: 1) Provide a Generic Clearance Submission Template for each Instrument. 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; 2) Upload each Generic Clearance Submission Template as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 3) 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	04/30/2019	36 Months From Approved	04/30/2016
Responses	1,000,000	0	1,000,000
Time Burden (Hours)	50,000	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: 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:
	80 FR 66904	10/30/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 81550	12/30/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Beneficiary Contact Center Customer Satisfaction Survey	CMS-10415	IVR Phone Script for Survey
Cognitive Testing for the Marketplace Dental Survey (CMS-10591)	CMS-10591	Marketplace Dental Survey Cognitive Testing Eligibility Screener
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2	GenIC#5	ESRD Greivant Satisfaction Survey Version 2.0
Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	CMS-10415	Stakeholder Training Forms
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
QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590)	CMS-10590	Quality Net User Survey
Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project (CMS-10534)	CMS-10534	Cognitive Interview Guide, Screener and Consent Forms
Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588)	CMS-10588	Usability Test Script

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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)	50,000	25,000	0	25,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Of the original 25,000 hours that were approved, CMS used 22,261 hours. We are seeking to carryover 6,566 hours and requesting an additional 43,434 hours, for a total of 50,000 hours.

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Annual Cost to Federal Government: $250,000

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]? Yes

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: 12/30/2015

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