MyMedicare.gov User 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⚠️ Notice: This information collection may be referencing outdated material.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 MyMedicare.gov User Satisfaction Survey Form and Instruction
CMS-10415 MyMedicare.gov Survey CMS-10415.Fast Track Survey - MyMedicaregov.docx Form and Instruction
CMS-10415.MyMedicare Survey - Clearance Template.doc CMS-10415.MyMedicare Survey - Clearance Template IC Document
Supplemental Info - MyMedicare.gov Survey.docx Supplemental Information IC Document

Information Collection (IC) Details

IC Title:	MyMedicare.gov User 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	MyMedicare.gov Survey	CMS-10415.Fast Track Survey - MyMedicaregov.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: 6,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10415.MyMedicare Survey - Clearance Template	CMS-10415.MyMedicare Survey - Clearance Template.doc	07/26/2017
Supplemental Information	Supplemental Info - MyMedicare.gov Survey.docx	12/26/2017

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