Information Collection

Beneficiary Surveys

IC 226869 under ICR 201705-0938-008 · OMB 0938-1332.

Documents and Forms

Document Name Document Type
Form CMS-10635 Beneficiary Surveys Form
CMS-10635 Enrollee Beneficiary Survey (Screen Shots) MontanaHELP_enrollee_screenshots_rev1-508-sm.pdf Form
CMS-10635 Disenrollee and Lockout Beneficiary Survey (Screen Shots MontanaHELP_disenrollee_screenshots_rev1-508-sm.pdf Form
CMS-10635 Beneficiary Survey: Enrollees (paper) RM002_MontanaQx_Enrollee_20170622_rev_clean.pdf Form
CMS-10635 Beneficiary Survey: Disenrollees (paper) RM002_MontanaQx_Disenrollee_20170622_rev_clean.pdf Form
CMS-10635 Beneficiary Survey: Enrollees (Spanish, paper) RM002_MontanaQx_Enrollee_20170622_EUS_rev_clean.pdf Form
CMS-10635 Beneficiary Survey: Disenrollees (Spanish, paper) RM002_MontanaQx_Disenrollee_20170622_EUS_rev_clean.pdf Form
CMS-10635 Beneficiary Survey: Revised Enrollee/Disenrollees Race Q Enrollee_Disenrollee_Race2_rev_clean.docx Form
HELP CoverLetter_English (OMB Passback 1)_rev_clean.docx Surver Cover Letter IC Document
HELP_ThankYouLetter (OMB Passback 1)_rev_clean.docx Survey Thank You IC Document
RMADA_Postcard_06222017_rev_clean.pdf Survey Reminder Postcard IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Beneficiary Surveys	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10635	Beneficiary Survey: Disenrollees (paper)	RM002_MontanaQx_Disenrollee_20170622_rev_clean.pdf	No		Paper Only
Form	CMS-10635	Enrollee Beneficiary Survey (Screen Shots)	MontanaHELP_enrollee_screenshots_rev1-508-sm.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10635	Disenrollee and Lockout Beneficiary Survey (Screen Shots)	MontanaHELP_disenrollee_screenshots_rev1-508-sm.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10635	Beneficiary Survey: Enrollees (paper)	RM002_MontanaQx_Enrollee_20170622_rev_clean.pdf	No		Paper Only
Form	CMS-10635	Beneficiary Survey: Enrollees (Spanish, paper)	RM002_MontanaQx_Enrollee_20170622_EUS_rev_clean.pdf	No		Paper Only
Form	CMS-10635	Beneficiary Survey: Revised Enrollee/Disenrollees Race Question (screen shots)	Enrollee_Disenrollee_Race2_rev_clean.docx	No		Fillable Fileable
Form	CMS-10635	Beneficiary Survey: Disenrollees (Spanish, paper)	RM002_MontanaQx_Disenrollee_20170622_EUS_rev_clean.pdf	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,400	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	1,400	1,400
Annual IC Time Burden (Hours)	350	350
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Surver Cover Letter	HELP CoverLetter_English (OMB Passback 1)_rev_clean.docx	06/23/2017
Survey Thank You	HELP_ThankYouLetter (OMB Passback 1)_rev_clean.docx	06/23/2017
Survey Reminder Postcard	RMADA_Postcard_06222017_rev_clean.pdf	06/23/2017

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