Beneficiary Contact Center Customer Satisfaction Survey

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

⚠️ Notice: This information collection may be referencing outdated material.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

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.