Information Collection

Consumer Survey

IC 226369 under ICR 202105-0938-002 · OMB 0938-1342.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1342 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10632 Consumer Survey	Form and Instruction
CMS-10632 Appendix B Consumer Survey: Informed Consent and Survey CMS-10632.Appendix_B_Consumer_Survey_srs_022221.pdf	Form and Instruction

IC Title:

Consumer 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10632	Appendix B Consumer Survey: Informed Consent and Survey	CMS-10632.Appendix_B_Consumer_Survey_srs_022221.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	132	132
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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