CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey

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⚠️ Notice: This information collection may be referencing outdated material.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-10726 CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey Form and Instruction
CMS-10726 Consumer and Issuer Recruitment Language Attachment A-Consumer and Issuer Recruitment Language (FG and CT).docx Form and Instruction
CMS-10726 Consent Forms Attachment B-Consent Forms.docx Form and Instruction
CMS-10726 Descripton of Focus Groups and Cognitive Testing Protoco Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020.docx Form and Instruction
CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN.docx CMS-10726 Generic Clearance IC Document

Information Collection (IC) Details

IC Title:	CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey	Agency IC Tracking Number:

IC Status: New

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-10726	Consumer and Issuer Recruitment Language	Attachment A-Consumer and Issuer Recruitment Language (FG and CT).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10726	Consent Forms	Attachment B-Consent Forms.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10726	Descripton of Focus Groups and Cognitive Testing Protocols	Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10726 Generic Clearance	CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN.docx	02/24/2020

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