Information Collection

Surveying our Customers – Post-activity Evaluation (CMS-10732)

IC 242633 under ICR 201904-0938-017 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form
Form CMS-10732 Customer and Stakeholder Feedback: All (Webinar) Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form
CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers LEA Engagement Eval Prov.Supp (version 3).docx	Form
CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary LEA Engagement Eval Medicare Bene (version 3).docx	Form
CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer LEA Engagement Eval Marketplace Consumer (version 3).docx	Form
CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assiste LEA Engagement Eval SHIP or Other (version 3).docx	Form
CMS-10732 Customer and Stakeholder Feedback: All (Webinar) LEA Engagement Eval from Webinar Hyperlink (version 3).docx	Form
CMS-10732 - LEA Fast Track Supporting Statement (version 3).docx Fast Track Supporting Statement	IC Document

IC Title:

Surveying our Customers â Post-activity Evaluation (CMS-10732)

Agency IC Tracking Number:

OPOLE

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10732	No		Fillable Fileable
Form	CMS-10732	No		Fillable Fileable
Form	CMS-10732	No		Fillable Fileable
Form	CMS-10732	No		Fillable Fileable
Form	CMS-10732	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,320

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	22,320	22,320
Annual IC Time Burden (Hours)	1,116	1,116
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Supporting Statement		07/09/2020

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

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