Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10820 CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007	Form and Instruction	New	Repair queued
Form CMS-10820 CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803	Form and Instruction	New	Repair queued
Form CMS-10828 Post-webinar Feedback Survey	Form and Instruction	New	Repair queued
Form CMS-10815 CMS-10815. Call Center Questions	Form	New	Repair queued
Form CMS-10814 CMS-10814. Written Correspondence Instrument	Form	New	Repair queued
Form CMS-10813 Web Chat Survey	Form	New	Repair queued
Form CMS-10812 CMS-10812. Audit and Reimbursement - Letter	Form	New	Repair queued
Form CMS-10812 CMS-10812. Audit and Reimbursement - Website	Form	New	Repair queued
Form CMS-10811 CMS-10811. Appendix B_Part D Survey Questions FINAL	Form and Instruction	New	Repair queued
Form CMS-10811 CMS-10811. Appendix A_Part C Survey Questions FINAL	Form and Instruction	New	Repair queued
Form CMS-10754 Observed Testing Protocol	Form and Instruction	New	Repair queued
Form CMS-10754 GADCS Feedback Application	Form and Instruction	New	Repair queued
Form CMS-10771 IPRO Collaborator - Community of Care Coalitions Survey	Form and Instruction	New	Repair queued
Form CMS-10770 IPRO Collaborator Drug Safety Survey	Form and Instruction	New	Repair queued
Form CMS-10754 GADCS Feedback Application	Form and Instruction	New	Repair queued
Form CMS-10776 Collaoborator Survey Nursing Home	Form and Instruction	New	Repair queued
Form CMS-10748 Account Manager Satisfaction Survey	Form	New	Repair queued
Form CMS-10719 MACBIS Software Application Electronic Survey	Form	New	Repair queued
Form CMS-10766 COVID-19 Campaign Survey on Fee-for-Service CMS.gov	Form and Instruction	New	Repair queued
Form CMS-10763 CMS-10763.Medical Review Survey (English).docx	Form and Instruction	New	Repair queued
Form CMS-10763 CMS-10763.Medical Review Survey (Spanish).docx	Form and Instruction	New	Repair queued
Form CMS-10762 CMS-10762.Final Persistent Mobile Feedback Survey (English)	Form and Instruction	New	Repair queued
Form CMS-10762 : CMS-10762.Final Persistent Mobile Application Feedback Survey (Spanish)	Form and Instruction	New	Repair queued
Form CMS-10761 CMS-10761.Final Overall Mobile Application Feedback Survey (Spanish)	Form and Instruction	New	Repair queued
Form CMS-10761 CMS-10761.Final Overall Mobile Feedback Survey (English)	Form and Instruction	New	Repair queued
Form CMS-10760 Overall Flu Campaign Feedback Survey	Form and Instruction	New	Repair queued
Form CMS-10750 NW 0 Colaborator Survey	Form and Instruction	New	Repair queued
Form CMS-10750 NW 6 Colaborator Survey	Form and Instruction	New	Repair queued
Form CMS-10750 NW 2 Colaborator Survey	Form and Instruction	New	Repair queued
Form CMS-10750 NW 1 Colaborator Survey	Form and Instruction	New	Repair queued
Form CMS-10748 Account Manager Satisfaction Survey	Form	New	Repair queued
Form CMS-10746 Script: Medicare Casework Customer Satisfaction Survey	Form and Instruction	New	Repair queued
Form CMS-10732 Customer and Stakeholder Feedback: All (Webinar)	Form	New	Repair queued
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner	Form	New	Repair queued
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer	Form	New	Repair queued
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary	Form	New	Repair queued
Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers	Form	New	Repair queued
Form CMS-10729 Beneficiary Satisfaction Survey	Form and Instruction	New	Repair queued
Form CMS-10723 Patient Activation Survey	Form and Instruction	New	Repair queued
Form CMS-10726 Descripton of Focus Groups and Cognitive Testing Protocols	Form and Instruction	New	Available
Form CMS-10726 Consent Forms	Form and Instruction	New	Available
Form CMS-10726 Consumer and Issuer Recruitment Language	Form and Instruction	New	Available
Form CMS-10721 Final Persistent Portal Feedback Survey (Spanish)	Form and Instruction	New	Repair queued
Form CMS-10721 Final Persistent Portal Feedback Survey	Form and Instruction	New	Repair queued
Form CMS-10721 Final Persistent Website Feedback Survey (Spanish)	Form and Instruction	New	Repair queued
Form CMS-10721 Final Persistent Website Feedback Survey	Form and Instruction	New	Repair queued
Form CMS-10720 Final Overall Portal Feedback Survey.docx	Form and Instruction	New	Available
Form CMS-10720 Final Overall Website Feedback Survey (Spanish).docx	Form and Instruction	New	Available
Form CMS-10720 Final Overall Portal Feedback Survey (Spanish)	Form and Instruction	New	Available
Form CMS-10720 Overall Website Feedback Survey.docx	Form and Instruction	New	Available
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users	Form	New	Available
Form CMS-10415.GenIC #5 End Stage Renal Disease (ESRD) Grievant Satisfaction Survey	Form and Instruction	New	Available
Form CMS-10682 CMS-10682.CMS_OCS_TestingQuestions_SitemapTesting	Form	New	Available
Form CMS-10679 EMDI_Workgroup_Participation_Survey	Form and Instruction	New	Available
Form CMS-10676 Medicare.gov Sitewide Qualtrics Survey	Form and Instruction	New	Available
Form CMS-10415 Medicaregov - Medicare Plan Finder Survey	Form and Instruction	New	Available
Form CMS-10415 CMS.gov User Satisfaction Survey	Form and Instruction	New	Available
Form CMS-10626 CrownWeb Facility User Survey	Form and Instruction	New	Available
Form CMS-10590 QualityNetPortal_UserSurvey	Form and Instruction	New	Available
Form CMS-10588 Usability Test Script	Form and Instruction	New	Available
Form CMS-10534 Cognitive Interview Guide, Screener and Consent Forms	Form and Instruction	New	Available
Form CMS-10415 Evaluation of Stakeholder Training	Form and Instruction	New	Available
Form CMS-10415 IVR Phone Script	Form and Instruction	New	Available
CMS-10415_Supporting Statement A - FINAL 10-8-19.docx	Supporting Statement A	Uploaded 2019-10-08	Available
CMS-10415_Supporting_Statement_Part_B 2019.doc	Supporting Statement B	Uploaded 2019-04-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
256602	Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	Form and Instruction	New	CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007
256602	Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	Form and Instruction	New	CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803
256182	Replacing Durable Medical Equipment & Prescription Drugs after a Disaster: Addressing the Needs of Medicare Beneficiaries" post-training feedback survey (CMS-10828)	Form and Instruction	New	Post-webinar Feedback Survey
254305	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815)	Form	New	CMS-10815. Call Center Questions
254304	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814)	Form	New	CMS-10814. Written Correspondence Instrument
254302	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813)	Form	New	Web Chat Survey
254301	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)	Form	New	CMS-10812. Audit and Reimbursement - Letter
254301	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)	Form	New	CMS-10812. Audit and Reimbursement - Website
254250	Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)	Form and Instruction	New	CMS-10811. Appendix B_Part D Survey Questions FINAL
254250	Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)	Form and Instruction	New	CMS-10811. Appendix A_Part C Survey Questions FINAL
252264	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New	Observed Testing Protocol
252264	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Instruction	New
252264	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New	GADCS Feedback Application
251420	IPRO Community of Care Coalitions Collaborator Survey (CMS-10771)	Form and Instruction	New	IPRO Collaborator - Community of Care Coalitions Survey
251419	IPRO Drug Safety Program Collaborator Survey (CMS-10770)	Form and Instruction	New	IPRO Collaborator Drug Safety Survey
248567	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Instruction	New
248567	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New	GADCS Feedback Application
247324	(CMS-10776) IPRO 2020 Collaborator Satisfaction Survey-Request for Approval-Nursing Homes	Form and Instruction	New	Collaoborator Survey Nursing Home
246099	Account Manager Satisfaction Survey (CMS-10748)	Form	New	Account Manager Satisfaction Survey
245112	MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Form	New	MACBIS Software Application Electronic Survey
244519	CMS-10766. COVID-19 Campaign Survey on Fee-for-Service CMS.gov	Form and Instruction	New	COVID-19 Campaign Survey on Fee-for-Service CMS.gov
244015	CMS-10763.Medicare Administrative Contactors Customer Experience – Medical Review	Form and Instruction	New	CMS-10763.Medical Review Survey (English).docx
244015	CMS-10763.Medicare Administrative Contactors Customer Experience – Medical Review	Form and Instruction	New	CMS-10763.Medical Review Survey (Spanish).docx
244014	CMS-10762. Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application	Form and Instruction	New	CMS-10762.Final Persistent Mobile Feedback Survey (English)
244014	CMS-10762. Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application	Form and Instruction	New	: CMS-10762.Final Persistent Mobile Application Feedback Survey (Spanish)
244004	CMS-10761. Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application	Form and Instruction	New	CMS-10761.Final Overall Mobile Application Feedback Survey (Spanish)
244004	CMS-10761. Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application	Form and Instruction	New	CMS-10761.Final Overall Mobile Feedback Survey (English)
243962	CMS-10760.Overall Flu Campaign Feedback Survey	Form and Instruction	New	Overall Flu Campaign Feedback Survey
243030	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	NW 0 Colaborator Survey
243030	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	NW 6 Colaborator Survey
243030	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	NW 2 Colaborator Survey
243030	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	NW 1 Colaborator Survey
242918	Account Manager Satisfaction Survey (CMS-10748)	Form	New	Account Manager Satisfaction Survey
242711	Medicare Casework Customer Satisfaction Survey (CMS-10746)	Form and Instruction	New	Script: Medicare Casework Customer Satisfaction Survey
242633	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: All (Webinar)
242633	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: SHIP or Other Assister or Partner
242633	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Marketplace Consumer
242633	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Medicare Beneficiary
242633	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Providers/Suppliers
241657	Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	Form and Instruction	New	Beneficiary Satisfaction Survey
241125	(CMS-10723) 12SOW Patient Activiation Assessment	Form and Instruction	New	Patient Activation Survey
240090	CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey	Form and Instruction	New	Descripton of Focus Groups and Cognitive Testing Protocols
240090	CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey	Form and Instruction	New	Consent Forms
240090	CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey	Form and Instruction	New	Consumer and Issuer Recruitment Language
238683	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New	Final Persistent Portal Feedback Survey (Spanish)
238683	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New	Final Persistent Portal Feedback Survey
238683	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New	Final Persistent Website Feedback Survey (Spanish)
238683	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New	Final Persistent Website Feedback Survey
238682	Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New	Final Overall Portal Feedback Survey.docx
238682	Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New	Final Overall Website Feedback Survey (Spanish).docx
238682	Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New	Final Overall Portal Feedback Survey (Spanish)
238682	Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New	Overall Website Feedback Survey.docx
238454	MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Form	New	MACBIS Software Application Electronic Surveys for Users
235903	End Stage Renal Disease Grievant Satisfaction Survey	Form and Instruction	New	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey
235902	Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682)	Form	New	CMS-10682.CMS_OCS_TestingQuestions_SitemapTesting
235900	Electronic Medical Documentation Interoperability (EMDI) Workgroup Survey (CMS-10679)	Form and Instruction	New	EMDI_Workgroup_Participation_Survey
235899	Medicare.gov Sitewide Qualtrics (CMS-10676)	Form and Instruction	New	Medicare.gov Sitewide Qualtrics Survey
235898	Medicaregov - Medicare Plan Finder Survey	Form and Instruction	New	Medicaregov - Medicare Plan Finder Survey
235897	CMS.gov User Satisfaction Survey	Form and Instruction	New	CMS.gov User Satisfaction Survey
235896	End Stage Renal Disease Quality Reporting System (EQRS) Customer Satisfaction and Task Prioritization Survey for the EQRS Release 1.0 Project (CMS-10626)	Form and Instruction	New	CrownWeb Facility User Survey
235895	QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS- 10590)	Form and Instruction	New	QualityNetPortal_UserSurvey
235894	Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588)	Form and Instruction	New	Usability Test Script
235891	Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys (CMS-10534)	Form and Instruction	New	Cognitive Interview Guide, Screener and Consent Forms
235888	Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	Form and Instruction	New	Evaluation of Stakeholder Training
235885	Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction	New	IVR Phone Script

ICR Details

OMB Control No: 0938-1185	ICR Reference No: 201904-0938-017
Status: Historical Active	Previous ICR Reference No: 201611-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: OC
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/05/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/30/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved	11/30/2019
Responses	1,000,000	0	1,000,000
Time Burden (Hours)	50,000	0	50,000
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the agency's programs. This feedback will provide insights into customer or stakeholder perceptions, experiences and expectations, provide an early warning of issues with service, or focus attention on areas where communication, training or changes in operations might improve delivery of products or services. These collections will allow for ongoing, collaborative and actionable communications between the Agency and its customers and stakeholders. It will also allow feedback to contribute directly to the improvement of program management.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 7063	03/01/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 18289	04/30/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 41

table that charts list of burden

IC Title	Form No.	Form Name
(CMS-10723) 12SOW Patient Activiation Assessment	CMS-10723	Patient Activation Survey
(CMS-10776) IPRO 2020 Collaborator Satisfaction Survey-Request for Approval-Nursing Homes	CMS-10776	Collaoborator Survey Nursing Home
Account Manager Satisfaction Survey (CMS-10748)	CMS-10748	Account Manager Satisfaction Survey
Account Manager Satisfaction Survey (CMS-10748)	CMS-10748	Account Manager Satisfaction Survey
Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	CMS-10729	Beneficiary Satisfaction Survey
Beneficiary Contact Center Customer Satisfaction Survey	CMS-10415	IVR Phone Script
CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey	CMS-10726, CMS-10726, CMS-10726	Consumer and Issuer Recruitment Language ,   Consent Forms ,   Descripton of Focus Groups and Cognitive Testing Protocols
CMS-10760.Overall Flu Campaign Feedback Survey	CMS-10760	Overall Flu Campaign Feedback Survey
CMS-10761. Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application	CMS-10761, CMS-10761	CMS-10761.Final Overall Mobile Feedback Survey (English) ,   CMS-10761.Final Overall Mobile Application Feedback Survey (Spanish)
CMS-10762. Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application	CMS-10762, CMS-10762	: CMS-10762.Final Persistent Mobile Application Feedback Survey (Spanish) ,   CMS-10762.Final Persistent Mobile Feedback Survey (English)
CMS-10763.Medicare Administrative Contactors Customer Experience – Medical Review	CMS-10763, CMS-10763	CMS-10763.Medical Review Survey (Spanish).docx ,   CMS-10763.Medical Review Survey (English).docx
CMS-10766. COVID-19 Campaign Survey on Fee-for-Service CMS.gov	CMS-10766	COVID-19 Campaign Survey on Fee-for-Service CMS.gov
CMS.gov User Satisfaction Survey	CMS-10415	CMS.gov User Satisfaction Survey
Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	CMS-10820, CMS-10820	CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803 ,   CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007
Electronic Medical Documentation Interoperability (EMDI) Workgroup Survey (CMS-10679)	CMS-10679	EMDI_Workgroup_Participation_Survey
End Stage Renal Disease Grievant Satisfaction Survey	CMS-10415.GenIC #5	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey
End Stage Renal Disease Quality Reporting System (EQRS) Customer Satisfaction and Task Prioritization Survey for the EQRS Release 1.0 Project (CMS-10626)	CMS-10626	CrownWeb Facility User Survey
Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	CMS-10415	Evaluation of Stakeholder Training
IPRO Community of Care Coalitions Collaborator Survey (CMS-10771)	CMS-10771	IPRO Collaborator - Community of Care Coalitions Survey
IPRO Drug Safety Program Collaborator Survey (CMS-10770)	CMS-10770	IPRO Collaborator Drug Safety Survey
IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	CMS-10750 , CMS-10750, CMS-10750, CMS-10750	NW 1 Colaborator Survey ,   NW 2 Colaborator Survey ,   NW 6 Colaborator Survey ,   NW 0 Colaborator Survey
MACBIS Software Application Electronic Surveys for Users (CMS-10719)	CMS-10719	MACBIS Software Application Electronic Surveys for Users
MACBIS Software Application Electronic Surveys for Users (CMS-10719)	CMS-10719	MACBIS Software Application Electronic Survey
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)	CMS-10812, CMS-10812	CMS-10812. Audit and Reimbursement - Website ,   CMS-10812. Audit and Reimbursement - Letter
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813)	CMS-10813	Web Chat Survey
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815)	CMS-10815	CMS-10815. Call Center Questions
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814)	CMS-10814	CMS-10814. Written Correspondence Instrument
Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	CMS-10720, CMS-10720, CMS-10720, CMS-10720	Overall Website Feedback Survey.docx ,   Final Overall Portal Feedback Survey (Spanish) ,   Final Overall Website Feedback Survey (Spanish).docx ,   Final Overall Portal Feedback Survey.docx
Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	CMS-10721, CMS-10721, CMS-10721, CMS-10721	Final Persistent Website Feedback Survey ,   Final Persistent Website Feedback Survey (Spanish) ,   Final Persistent Portal Feedback Survey ,   Final Persistent Portal Feedback Survey (Spanish)
Medicare Casework Customer Satisfaction Survey (CMS-10746)	CMS-10746	Script: Medicare Casework Customer Satisfaction Survey
Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)	CMS-10811, CMS-10811	CMS-10811. Appendix A_Part C Survey Questions FINAL ,   CMS-10811. Appendix B_Part D Survey Questions FINAL
Medicare.gov Sitewide Qualtrics (CMS-10676)	CMS-10676	Medicare.gov Sitewide Qualtrics Survey
Medicaregov - Medicare Plan Finder Survey	CMS-10415	Medicaregov - Medicare Plan Finder Survey
QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS- 10590)	CMS-10590	QualityNetPortal_UserSurvey
Replacing Durable Medical Equipment & Prescription Drugs after a Disaster: Addressing the Needs of Medicare Beneficiaries" post-training feedback survey (CMS-10828)	CMS-10828	Post-webinar Feedback Survey
Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys (CMS-10534)	CMS-10534	Cognitive Interview Guide, Screener and Consent Forms
Surveying our Customers – Post-activity Evaluation (CMS-10732)	CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732	Customer and Stakeholder Feedback: Providers/Suppliers ,   Customer and Stakeholder Feedback: Medicare Beneficiary ,   Customer and Stakeholder Feedback: Marketplace Consumer ,   Customer and Stakeholder Feedback: SHIP or Other Assister or Partner ,   Customer and Stakeholder Feedback: All (Webinar)
Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682)	CMS-10682	CMS-10682.CMS_OCS_TestingQuestions_SitemapTesting
Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588)	CMS-10588	Usability Test Script
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	CMS-10754	GADCS Feedback Application
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	CMS-10754, CMS-10754	GADCS Feedback Application ,   Observed Testing Protocol

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000,000	1,000,000	0	0	0	0
Annual Time Burden (Hours)	50,000	50,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $250,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/30/2019

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