Information Collection

Beneficiary Contact Center Customer Satisfaction Survey

IC 219431 under ICR 201512-0938-013 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10415 Beneficiary Contact Center Customer Satisfaction Survey Form and Instruction
CMS-10415 IVR Phone Script for Survey IVR Phone Script.docx Form and Instruction
IVR Survey Submission form.doc IVR Survey Submission Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Beneficiary Contact Center Customer Satisfaction Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10415	IVR Phone Script for Survey	IVR Phone Script.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 145,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	145,000	145,000
Annual IC Time Burden (Hours)	5,776	5,776
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
IVR Survey Submission Form	IVR Survey Submission form.doc	12/29/2015

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