Information Collection

Survey Administration

IC 223944 under ICR 201610-0938-002 · OMB 0938-1322.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10597 Survey Administration	Form and Instruction
CMS-10597 Healthcare.gov Site Wide Survey CMS-10597.HCgov_SiteWideSurvey Instrument.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10597	Healthcare.gov Site Wide Survey	CMS-10597.HCgov_SiteWideSurvey Instrument.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	1,600	1,600
Annual IC Time Burden (Hours)	933	933
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.