Medicare Beneficiary and Family-Centered Satisfaction Survey

Beneficiary and Family Centered Data Collection (CMS-10393)

OMB: 0938-1177

IC ID: 201543

Information Collection (IC) Details

View Information Collection (IC)

Medicare Beneficiary and Family-Centered Satisfaction Survey
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

9,100 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 9,100 0 0 -15,870 0 24,970
Annual IC Time Burden (Hours) 2,191 0 0 -708 0 2,899
Annual IC Cost Burden (Dollars) 11,375 0 0 -19,838 0 31,213

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.

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