CMS-10686 Supporting Statement

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 0938-NEW)

TITLE OF INFORMATION COLLECTION: 2018 Resource Assessment

PURPOSE: Quality Insight seeks to learn the efficacy of our information dissemination over
the past four years and how to improve moving forward. We are asking our providers and
partners what their learning habits and needs are in the face of ever changing technology, and we
intend to use this information to inform our future plans. The results of this information
collection device will not be shared beyond our internal staff and subcontractors. Respondents
will be anonymous.

DESCRIPTION OF RESPONDENTS: Quality Insights LAN members and partners

TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software)
[ ] Focus Group

[ X] Customer Satisfaction Survey
[ ] Small Discussion Group
[ ] Other: ______________________

CERTIFICATION:
I certify the following to be true:
1. The collection is voluntary.
2. The collection is low-burden for respondents and low-cost for the Federal Government.
3. The collection is non-controversial and does not raise issues of concern to other federal
agencies.
4. The results are not intended to be disseminated to the public.
5. Information gathered will not be used for the purpose of substantially informing influential
policy decisions.
6. The collection is targeted to the solicitation of opinions from respondents who have
experience with the program or may have experience with the program in the future.
Name:_____Krista Davis, Quality Insights Assistant Director of Communications____________
To assist review, please provide answers to the following question:
Personally Identifiable Information:

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1. Is personally identifiable information (PII) collected? [ ] Yes [X ] No
2. If Yes, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] No
3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No
Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [ X ] No

BURDEN HOURS
Category of Respondent

No. of
Participation
Respondents Time
9,692
5 minutes

Private sector

Burden
808

Totals
FEDERAL COST: The estimated annual cost to the Federal government is _$0___________
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents
1. Do you have a customer list or something similar that defines the universe of potential
respondents and do you have a sampling plan for selecting from this universe?
[X ] Yes
[ ] No
If the answer is yes, please provide a description of both below (or attach the sampling plan)? If
the answer is no, please provide a description of how you plan to identify your potential group of
respondents and how you will select them?
Respondents consist of providers, partners and stakeholders that participated in at least one of
our 11th Scope of Work Learning and Action Networks.

Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[ X ] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [ X ] No
Please make sure that all instruments, instructions, and scripts are submitted with the
request.
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Link to Information collection device: https://www.surveymonkey.com/r/27HY8SJ
PDF copy is attached.

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