OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Beneficiary Surveys

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

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10635
Enrollee Beneficiary Survey (Screen Shots) Beneficiary Surveys		 Form
Form CMS-10635
Disenrollee and Lockout Beneficiary Survey (Screen Shots) Beneficiary Surveys		 Form
Form CMS-10635
Beneficiary Survey: Enrollees (paper) Beneficiary Surveys		 Form
Form CMS-10635
Beneficiary Survey: Disenrollees (paper) Beneficiary Surveys		 Form
Form CMS-10635
Beneficiary Survey: Enrollees (Spanish, paper) Beneficiary Surveys		 Form
Form CMS-10635
Beneficiary Survey: Disenrollees (Spanish, paper) Beneficiary Surveys		 Form
Form CMS-10635
Beneficiary Survey: Revised Enrollee/Disenrollees Race Question (screen shots) 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)

layout table

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 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

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,400 0 1,400 0 0 0
Annual IC Time Burden (Hours) 350 0 350 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
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.