Information Collection

CMS-10676.Medicare.gov Sitewide Qualtrics Survey

IC 231881 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10676 CMS-10676.Medicare.gov Sitewide Qualtrics Survey Form and Instruction
CMS-10676 Medicare.gov Sitewide Qualtrics Survey CMS-10676.Medicare.gov Sitewide Qualtrics Survey.docx Form and Instruction
CMS-10676.Generic Clearance Template (MedicareQualtrics) FINAL.doc CMS-10676.Generic Clearance Template (MedicareQualtrics) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CMS-10676.Medicare.gov Sitewide Qualtrics 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-10676	Medicare.gov Sitewide Qualtrics Survey	CMS-10676.Medicare.gov Sitewide Qualtrics Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	8,333	8,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10676.Generic Clearance Template (MedicareQualtrics)	CMS-10676.Generic Clearance Template (MedicareQualtrics) FINAL.doc	06/20/2018

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