Medicare Beneficiary and Family-Centered Satisfaction Survey

(CMS-10393) Beneficiary and Family Centered Data Collection

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.