Information Collection

MA-Only CAHPS Field Test Survey

IC 251370 under ICR 202201-0938-021 · OMB 0938-1432.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10793 MA-Only CAHPS Field Test Survey	Form and Instruction
Form CMS-10793 2022 Medicare Advantage Plan Survey Field Test Version MA-Only CAHPS Field Test Survey	Form and Instruction
CMS-10793 2022 Medicare Advantage Plan Survey Field Test Version 2022 MA-Only Field Test Survey_1-26-22.pdf	Form and Instruction
CMS-10793 2022 Medicare Advantage Plan Survey Field Test Version 2022 MA-Only Field Test Survey_1-26-22.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

MA-Only CAHPS Field Test Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR Part 422 Section 152 42 CFR Part 423 Section 156 42 CFR Part 417 Section 472 (To search for a specific CFR, visit the Code of Federal Regulations.)

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-10793				Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Health Plan Management System (HPMS)

FR Citation: 83 FR 6591

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,120	1,120
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.

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