Information Collection

Beneficiary Contact Center Customer Satisfaction Survey

IC 219431 under ICR 201611-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

IC Title:

Beneficiary Contact Center Customer Satisfaction Survey

Agency IC Tracking Number:

IC Status: Unchanged

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-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 %

table that charts list of burden
	Requested	Previously Approved
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

table that charts IC Documents
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.