Information Collection

Medicare Beneficiary and Family-Centered Satisfaction Survey

IC 201543 under ICR 202010-0938-001 · OMB 0938-1177.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1177 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10393 12th_SOW_Direct Follow-up Instructions_Attachment_F_04 05 2017.docx	Instruction
CMS-10393 12th_SOW_Telephone Instructions_Attachment_E_04 05 2017.docx	Instruction
CMS-10393 12th_SOW_Written Survey Instructions_G_04 05 2017.docx	Instruction
CMS-10393 12th_SOW_Web Survey Instructions.docx	Instruction
CMS-10393 Attachment A: Beneficiary Experience Survey CMS-10393-BeneficiaryExperienceSurvey-AttB.pdf	Form and Instruction
CMS-10393 Attachment B: Direct Follow-up CMS-10393-DirectFollow-upScript-AtttC.pdf	Form and Instruction
CMS-10393 Attachment C: General Feedback Web Survey CMS-10393-GeneralFeedbackWebSurvey-AttD.pdf	Form and Instruction
CMS-10393 11th_SOW_Related Legislation_Attachment_D_04 05 2017.docx Legislation	IC Document

IC Title:

Medicare Beneficiary and Family-Centered Satisfaction Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10393	Attachment A: Beneficiary Experience Survey	CMS-10393-BeneficiaryExperienceSurvey-AttB.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10393	Attachment B: Direct Follow-up	CMS-10393-DirectFollow-upScript-AtttC.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-10393 12th_SOW_Direct Follow-up Instructions_Attachment_F_04 05 2017.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10393	Attachment C: General Feedback Web Survey	CMS-10393-GeneralFeedbackWebSurvey-AttD.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-10393 12th_SOW_Telephone Instructions_Attachment_E_04 05 2017.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10393 12th_SOW_Written Survey Instructions_G_04 05 2017.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10393 12th_SOW_Web Survey Instructions.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	9,100	-15,870	24,970
Annual IC Time Burden (Hours)	2,191	-708	2,899
Annual IC Cost Burden (Dollars)	11,375	-19,838	31,213

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Legislation	CMS-10393 11th_SOW_Related Legislation_Attachment_D_04 05 2017.docx	07/05/2017

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