Information Collection

Community Care Customer Experience Survey

IC 242500 under ICR 202003-2900-011 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2020-2900-0876-T2 Community Care Customer Experience Survey	Form and Instruction
2020-2900-0876-T2 Community Care Survey Wireframes 190032 VEO Project Charter_Community Care Customer Service v4 (FINAL Signed).pdf	Form and Instruction
Service Level Measurement - Community Care 062220 (002)).docx Statistical Sample Plan	IC Document
A-11 Fast-Track Clearance Reques_Community Care_(005).pdf A-11 Survey Requirements Document	IC Document

IC Title:

Community Care Customer Experience Survey

Agency IC Tracking Number:

2020-2900-0876-T

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2020-2900-0876-T2	Community Care Survey Wireframes	190032 VEO Project Charter_Community Care Customer Service v4 (FINAL Signed).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	54,000	54,000
Annual IC Time Burden (Hours)	2,700	2,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Statistical Sample Plan	Service Level Measurement - Community Care 062220 (002)).docx	06/29/2020
A-11 Survey Requirements Document	A-11 Fast-Track Clearance Reques_Community Care_(005).pdf	06/29/2020

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