MACBIS Software Application Electronic Surveys for Users (CMS-10719)

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users (CMS-10719) Form
CMS-10719 MACBIS Software Application Electronic Surveys for Users Instrument_MACBIS Software Application Electronic Surveys for Users (version 3) CLEAN.docx Form
CMS-10719 - Fast Track Supporting Statement (version 3).doc Fast Track Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Agency IC Tracking Number:	CMCS

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10719	MACBIS Software Application Electronic Surveys for Users	Instrument_MACBIS Software Application Electronic Surveys for Users (version 3) CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,081	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,081	2,081
Annual IC Time Burden (Hours)	173	173
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Fast Track Supporting Statement	CMS-10719 - Fast Track Supporting Statement (version 3).doc	11/08/2019

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