Information Collection

Medicare Beneficiary and Family-Centered Satisfaction Survey

IC 201543 under ICR 201707-0938-002 · OMB 0938-1177.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1177 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10393 Medicare Beneficiary and Family-Centered Satisfaction Survey	Form and Instruction
CMS-10393 11th_SOW_Direct Follow-up Instructions_Attachment_F_04 05 2017.docx	Instruction
CMS-10393 11th_SOW_Telephone Instructions_Attachment_E_04 05 2017.docx	Instruction
CMS-10393 11th_SOW_Written Survey Instructions_G_04 05 2017.docx	Instruction
CMS-10393 11th_SOW_Web Survey Instructions_Attachment_H_04 05 2017.docx	Instruction
CMS-10393 Attachment A: Beneficiary Experience Survey CMS-10393 11th_SOW_Beneficiary Experience Survey _Attachment_A_04 05 2017.docx	Form and Instruction
CMS-10393 Attachment B: Direct Follow-up CMS-10393 11th_SOW_Direct Follow Up _Attachment_B_04 05 2017.docx	Form and Instruction
CMS-10393 Attachment C: General Feedback Web Survey CMS-10393 11th_SOW_General Feedback Web survey_C_04 05 2017.docx	Form and Instruction
CMS-10393 11th_SOW_Related Legislation_Attachment_D_04 05 2017.docx Legislation	IC Document
CMS-10393_Survey Crosswalk_121117_FINAL.docx Crosswalk	IC Document

IC Title:

Medicare Beneficiary and Family-Centered Satisfaction Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10393	Attachment A: Beneficiary Experience Survey	CMS-10393 11th_SOW_Beneficiary Experience Survey _Attachment_A_04 05 2017.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10393	Attachment B: Direct Follow-up	CMS-10393 11th_SOW_Direct Follow Up _Attachment_B_04 05 2017.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10393 11th_SOW_Direct Follow-up Instructions_Attachment_F_04 05 2017.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10393	Attachment C: General Feedback Web Survey	CMS-10393 11th_SOW_General Feedback Web survey_C_04 05 2017.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10393 11th_SOW_Telephone Instructions_Attachment_E_04 05 2017.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10393 11th_SOW_Written Survey Instructions_G_04 05 2017.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10393 11th_SOW_Web Survey Instructions_Attachment_H_04 05 2017.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,970

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	24,970	8,960	16,010
Annual IC Time Burden (Hours)	2,899	-1,104	4,003
Annual IC Cost Burden (Dollars)	31,213	11,200	20,013

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Legislation	CMS-10393 11th_SOW_Related Legislation_Attachment_D_04 05 2017.docx	07/05/2017
Crosswalk	CMS-10393_Survey Crosswalk_121117_FINAL.docx	12/20/2017

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