Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10894 SBE Closeout	Form and Instruction	New	Repair queued
Form CMS-10894 Observation and Collaboration	Form and Instruction	New	Repair queued
Form CMS-10894 Conduct Reviews	Form and Instruction	New	Repair queued
Form CMS-10894 Data documentation Submission and Sampling	Form and Instruction	New	Repair queued
Form CMS-10894 Preparation: SMEs for IPPTA	Form and Instruction	New	Repair queued
Form CMS-10924 DevEx Survey.	Form and Instruction	New	Repair queued
Form CMS-10924 DevEx Survey	Form and Instruction	New	Repair queued
Form CMS-10811 CMS-10811.Appendix B_Part D IPM Survey Questions	Form and Instruction	New	Repair queued
Form CMS-10811 CMS-10811.Appendix A_Part C IPM Survey Questions	Form and Instruction	New	Repair queued
Form CMS-10903 CMS-10903. Attachment C - Consent form	Form and Instruction	New	Repair queued
Form CMS-10903.Attachme CMS-10903.Attachment B - Medicare Enrollee Eligibility Screener	Form and Instruction	New	Repair queued
Form CMS-10903 CMS-10903. Attachment A - Generative In-Depth Interview Guide	Form and Instruction	New	Repair queued
Form CMS-10872 CMS Applicant Information Collection Form	Form and Instruction	New	Repair queued
Form CMS-10892 Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form	Form and Instruction	New	Repair queued
Form CMS-10894 SBE Closeout	Form and Instruction	New	Repair queued
Form CMS-10894 Observation and Collaboration	Form and Instruction	New	Repair queued
Form CMS-10894 Conduct Reviews	Form and Instruction	New	Repair queued
Form CMS-10894 Data documentation Submission and Sampling	Form and Instruction	New	Repair queued
Form CMS-10894 Preparation: SMEs for IPPTA	Form and Instruction	New	Repair queued
Form CMS-10890 2024 CMS Health Equity Conference Feedback Survey	Form and Instruction	New	Repair queued
Form CMS-10889 QHP Cognitive Testing Survey	Form	New	Repair queued
Form CMS-10889 Testing Protocol	Form	New	Repair queued
Form CMS-10889 Recruitment Screener	Form	New	Repair queued
Form CMS-10889 QHP Cognitive Testing Consumer Consent Form	Form	New	Repair queued
Form CMS-10748 ACA Issuers Survey	Form	New	Repair queued
Form CMS-10748 Medicare Advantage Organization Survey	Form	New	Repair queued
Form CMS-10748 PACE Organization Survey	Form	New	Repair queued
Form CMS-10880 Focus Group Session Moderator Guide Script	Form and Instruction	New	Repair queued
Form CMS-10880 VRDC Survey Questions	Form and Instruction	New	Repair queued
Form CMS-10876 Provider Communication Needs Survey (final).docx	Form and Instruction	New	Repair queued
Form CMS-10879 Post-Conference Event Feedback Request	Form and Instruction	New	Repair queued
Form CMS-10873 Post-Event/Post-Training Survey	Form and Instruction	New	Repair queued
Form CMS-10826 5 - CMS-10827. Mod Guide B - Open Payments Consumer (revised)	Form and Instruction	New	Repair queued
Form CMS-10826 4 - CMS-10827. Mod Guide A - Open Payments Consumer (revised)	Form and Instruction	New	Repair queued
Form CMS-10826 3 - CMS-10827. Consent Form - Open Payments Consumer (revised)	Form and Instruction	New	Repair queued
Form CMS-10827 2 - CMS-10827. Recruitment Guide - Open Payments Consumer (revised)	Form and Instruction	New	Repair queued
Form CMS-10826 CMS-10826.Users-Checked Data (Physicians and Teaching Hospitals) (revised)	Form and Instruction	New	Repair queued
Form CMS-10826 CMS-10826.Health Care Providers (Primary Care and Specialist)	Form and Instruction	New	Repair queued
Form CMS-10826 CMS-10826.Recruitment Guide for Physicians and Other Health Care Providers	Form and Instruction	New	Repair queued
Form CMS-10826 CMS-10826.Recruitment Guide – Teaching Hospital Representatives (revised).docx	Form and Instruction	New	Repair queued
Form CMS-10869 Attachment D: CMS QHP Enrollee Survey QHP Issuer Focus Group Protocol	Form and Instruction	New	Repair queued
Form CMS-10869 Attachment C: CMS QHP Enrollee Survey Consumer Focus Group Protocol	Form and Instruction	New	Repair queued
Form CMS-10869 Attachment B: Consent Forms for Consumers and Issuers	Form and Instruction	New	Repair queued
Form CMS-10869 Attachment A - Recruitment Screeners for Consumer and Issuer Focus Groups	Form and Instruction	New	Repair queued
Form CMS-10776 IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2023)	Form and Instruction	New	Repair queued
Form CMS-10770 DRAFT IPRO Drug Safety Program Collaborator Survey (2023)	Form and Instruction	New	Repair queued
Form CMS-10771 IPRO Partnership for Community Health Coalition Initiative Collaborator Survey (2023)	Form and Instruction	New	Repair queued
Form CMS-10750 DRAFT IPRO ESRD Network 9 Collaborator Survey (2023)	Form and Instruction	New	Repair queued
Form CMS-10750 DRAFT IPRO ESRD Network 6 Collaborator Survey (2023)	Form and Instruction	New	Repair queued
Form CMS-10750 DRAFT IPRO ESRD Network 2 Collaborator Survey (2023)	Form and Instruction	New	Repair queued
Form CMS-10750 DRAFT IPRO ESRD Network 1 Collaborator Survey (2023)	Form and Instruction	New	Repair queued
Form CMS-10864 Oral Health Survey Plan	Form and Instruction	New	Repair queued
Form CMS-10859 PSME Satisfaction Survey	Form and Instruction	New	Repair queued
Form CMS-10841 J.9 Customer Satisfaction Survey	Form and Instruction	New	Repair queued
Form CMS-10820 CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007.docx	Form and Instruction	New	Available
Form CMS-10820 CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803	Form and Instruction	New	Available
Form CMS-10820 Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	Form and Instruction	New	Repair queued
Form CMS-10828 Post-Webinar Feedback Survey	Form and Instruction	New	Available
Form CMS-10828 Replacing Durable Medical Equipment and Prescription Drugs after a Disaster Addressing the Needs of Medicare Beneficiaries Post-training Feedback Survey (CMS-10828)	Form and Instruction	New	Repair queued
Form CMS-10815 CMS-10815. Call Center Question List.docx	Form	New	Available
Form CMS-10815 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815)	Form	New	Missing upstream
Form CMS-10814 CMS-10814. Written Correspondence Instrument	Form	New	Available
Form CMS-10814 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814)	Form	New	Repair queued
Form CMS-10813 Web Chat Survey	Form	New	Available
Form CMS-10813 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813)	Form	New	Repair queued
Form CMS-10812 CMS-10812. Audit and Reimbursement - Letter	Form	New	Available
Form CMS-10812 CMS-10812. Audit and Reimbursement - Website	Form	New	Available
Form CMS-10812 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)	Form	New	Repair queued
Form CMS-10811 CMS-10811. Appendix B_Part D Survey Questions FINAL	Form and Instruction	New	Available
Form CMS-10811 CMS-10811. Appendix A_Part C Survey Questions FINAL	Form and Instruction	New	Available
Form CMS-10811 Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)	Form and Instruction	New	Missing upstream
Form CMS-10754 Observed Testing Protocol	Form and Instruction	New	Available
Form CMS-10754 GADCS Feedback Application	Form and Instruction	New	Available
Form CMS-10754 User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New	Repair queued
Form CMS-10771 IPRO Collaborator - Community of Care Coalitions Survey	Form and Instruction	New	Available
Form CMS-10771 IPRO Community of Care Coalitions Collaborator Survey (CMS-10771)	Form and Instruction	New	Repair queued
Form CMS-10770 IPRO Collaborator Drug Safety Survey	Form and Instruction	New	Available
Form CMS-10770 IPRO Drug Safety Program Collaborator Survey (CMS-10770)	Form and Instruction	New	Repair queued
Form CMS-10754 GADCS Feedback Application	Form and Instruction	New	Available
Form CMS-10754 User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New	Repair queued
Form CMS-10776 Collaborator Survey Nursing Home	Form and Instruction	New	Available
Form CMS-10776 IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776)	Form and Instruction	New	Repair queued
Form CMS-10748 Account Manager Survey	Form	New	Available
Form CMS-10748 Account Manager Satisfaction Survey (CMS-10748)	Form	New	Repair queued
Form CMS-10719 MACBIS Software Application Electronic Survey	Form	New	Available
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users - Webinar Survey Polling Questions (CMS-10719)	Form	New	Repair queued
Form CMS-10766 CMS-10766.Instrument for COVID-19 Campaign Page Feedback Survey	Form and Instruction	New	Available
Form CMS-10766 COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766)	Form and Instruction	New	Repair queued
Form CMS-10763 CMS-10763.Medical Review Survey - Spanish final	Form and Instruction	New	Available
Form CMS-10763 CMS-10763.Medical Review Survey - English final	Form and Instruction	New	Available
Form CMS-10763 Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763)	Form and Instruction	New	Repair queued
Form CMS-10762 CMS-10762.Final Persistent Mobil Application Feedback Survey (Spanish)	Form and Instruction	New	Available
Form CMS-10762 Final Persistent Mobile Feedback Survey	Form and Instruction	New	Available
Form CMS-10762 Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762)	Form and Instruction	New	Repair queued
Form CMS-10761 Final Overall Mobil Application Feedback Survey (Spanish)-final (1)	Form and Instruction	New	Available
Form CMS-10761 Final Overall Mobile Feedback Survey-final	Form and Instruction	New	Available
Form CMS-10761 Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761)	Form and Instruction	New	Repair queued
Form CMS-10760 Overall Flue Campaign Feedback Survey	Form and Instruction	New	Available
Form CMS-10760 Overall Flu Campaign Feedback Survey (CMS-10760)	Form and Instruction	New	Repair queued
Form CMS-10750 NW 9 Collaborator Survey	Form and Instruction	New	Available
Form CMS-10750 NW 6 Collaborator Survey	Form and Instruction	New	Available
Form CMS-10750 NW 2 Collaborator Survey	Form and Instruction	New	Available
Form CMS-10750 NW 1 Collaborator Survey	Form and Instruction	New	Available
Form CMS-10750 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	Repair queued
Form CMS-10748 Account Manager Satisfaction Survey	Form	New	Available
Form CMS-10748 Account Manager Satisfaction Survey (CMS-10748)	Form	New	Repair queued
Form CMS-10746 Script: Medicare Casework Customer Satisfaction Survey	Form and Instruction	New	Available
Form CMS-10746 Medicare Casework Customer Satisfaction Survey (CMS-10746)	Form and Instruction	New	Repair queued
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer (Spanish)	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers (Spanish)	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner (Spanish)	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary (Spanish)	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: All (Webinar)	Form	New	Repair queued
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers	Form	New	Available
Form CMS-10732 Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Repair queued
Form CMS-10729 Beneficiary Care Management Program Beneficiary Satisfaction Survey_041420	Form and Instruction	New	Available
Form CMS-10729 Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	Form and Instruction	New	Repair queued
Form CMS-10723 CMS-10723.Patient Activation Assessment	Form and Instruction	New	Available
Form CMS-10723 12th SOW Patient Activation Assessment (CMS-10723)	Form and Instruction	New	Repair queued
Form CMS10726 Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020	Form and Instruction	New	Available
Form CMS-10726 Attachment B-Consent Forms	Form and Instruction	New	Available
Form CMS-10726 Attachment A-Consumer and Issuer Recruitment Language (FG and CT)	Form and Instruction	New	Available
Form CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726)	Form and Instruction	New	Repair queued
Form CMS-10721 CMS-10721.Final Persistent Website Feedback Survey (Spanish)	Form and Instruction	New	Available
Form CMS-10721 CMS-10721.Final Persistent Website Feedback Survey	Form and Instruction	New	Available
Form CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey (Spanish)	Form and Instruction	New	Available
Form CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey	Form and Instruction	New	Available
Form CMS-10721 Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New	Repair queued
Form CMS-10720 CMS-10720.Final Overall Portal Feedback Survey (Spanish)	Form and Instruction	New	Available
Form CMS-10720 CMS-10720.Final Overall Website Feedback Survey (Spanish)	Form and Instruction	New	Available
Form CMS-10720 Final Overall Portal Feedback Survey.docx	Form and Instruction	New	Available
Form CMS-10720 Final Overall Website Feedback Survey	Form and Instruction	New	Available
Form CMS-10720 Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New	Repair queued
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users	Form	New	Available
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Form	New	Repair queued
Form CMS-10415. GenIC#5 End Stage Renal Disease (ESRD) Grievant Satisfaction Survey	Form and Instruction	New	Available
Form CMS-10415. GenIC#5 End Stage Renal Disease Grievant Satisfaction Survey	Form and Instruction	New	Repair queued
Form CMS-10682 CMS_OCS_TestingQuestions_SitemapTesting.docx	Form	New	Available
Form CMS-10682 Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682)	Form	New	Repair queued
Form CMS-10676 Medicare.gov Sitewide Qualtrics Survey	Form and Instruction	New	Available
Form CMS-10676 Medicare.gov Sitewide Qualtrics Survey (CMS-10676)	Form and Instruction	New	Repair queued
Form CMS-10415 Medicare.gov - Medicare Plan Finder Survey	Form and Instruction	New	Available
Form CMS-10415 Medicaregov Medicare Plan Finder Survey	Form and Instruction	New	Repair queued
Form CMS-10415 CMS.gov User Satisfaction Survey	Form and Instruction	New	Repair queued
Form CMS-10415 CMS.gov User Satisfaction Survey	Form and Instruction	New	Repair queued
Form CMS-10590 CMS-10590.QualityNet_User_Survey	Form and Instruction	New	Available
Form CMS-10590 QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590)	Form and Instruction	New	Available
Form CMS-10588 Usability Test Script	Form and Instruction	New	Available
Form CMS-10588 Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588)	Form and Instruction	New	Repair queued
Form CMS-10415 IVR Phone Script	Form and Instruction	New	Available
Form CMS-10415 Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction	New	Repair queued
CMS-10415_Supporting Statement A - 2022.docx	Supporting Statement A	Uploaded 2022-11-29	Repair queued
CMS-10415_Supporting_Statement_Part_B.docx	Supporting Statement B	Uploaded 2022-11-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
279592	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	SBE Closeout
279592	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	Observation and Collaboration
279592	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	Conduct Reviews
279592	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	Data documentation Submission and Sampling
279592	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	Preparation: SMEs for IPPTA
279393	Blue Button API Developer Experience Customer Satisfaction Survey. (CMS-10924)	Form and Instruction	New	DevEx Survey.
275192	Blue Button 2.0 Developer Experience Customer Satisfaction Survey. (CMS-10924)	Form and Instruction	New	DevEx Survey
271652	CMS-10811. Medicare Parts C and D Improper Payment Measure (IPM) (REVISON)	Form and Instruction	New	CMS-10811.Appendix B_Part D IPM Survey Questions
271652	CMS-10811. Medicare Parts C and D Improper Payment Measure (IPM) (REVISON)	Form and Instruction	New	CMS-10811.Appendix A_Part C IPM Survey Questions
270304	Foundational Generative In-Depth Interviews for Medicare Enrollees Seeking Their Medicare Claims Data (CMS-10903)	Form and Instruction	New	CMS-10903. Attachment C - Consent form
270304	Foundational Generative In-Depth Interviews for Medicare Enrollees Seeking Their Medicare Claims Data (CMS-10903)	Form and Instruction	New	CMS-10903.Attachment B - Medicare Enrollee Eligibility Screener
270304	Foundational Generative In-Depth Interviews for Medicare Enrollees Seeking Their Medicare Claims Data (CMS-10903)	Form and Instruction	New	CMS-10903. Attachment A - Generative In-Depth Interview Guide
268190	Data Collection for Education and Outreach for the Yello System (CMS-10872)	Form and Instruction	New	CMS Applicant Information Collection Form
266611	Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form (CMS-10892)	Form and Instruction	New	Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form
266279	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	SBE Closeout
266279	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	Observation and Collaboration
266279	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	Conduct Reviews
266279	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	Data documentation Submission and Sampling
266279	Quality Improvement of IPPTA Processes and Procedures	Form and Instruction	New	Preparation: SMEs for IPPTA
265280	Health Equity Conference Satisfaction Survey and Interviews (CMS-10890)	Form and Instruction	New	2024 CMS Health Equity Conference Feedback Survey
264781	Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Cognitive Testing	Form	New	QHP Cognitive Testing Survey
264781	Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Cognitive Testing	Form	New	Testing Protocol
264781	Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Cognitive Testing	Form	New	Recruitment Screener
264781	Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Cognitive Testing	Form	New	QHP Cognitive Testing Consumer Consent Form
263808	Account Manager Satisfaction Survey (CMS-10748)	Form	New	ACA Issuers Survey
263808	Account Manager Satisfaction Survey (CMS-10748)	Form	New	Medicare Advantage Organization Survey
263808	Account Manager Satisfaction Survey (CMS-10748)	Form	New	PACE Organization Survey
263808	Account Manager Satisfaction Survey (CMS-10748)	Other-Emails to Plan Sponsors	New
263715	CCW VRDC Stakeholder Engagement Plan (CMS-10880)	Form and Instruction	New	Focus Group Session Moderator Guide Script
263715	CCW VRDC Stakeholder Engagement Plan (CMS-10880)	Form and Instruction	New	VRDC Survey Questions
263677	Medicare Fee-for-Service Provider Communications Preferences Survey (CMS-10876)	Form and Instruction	New	Provider Communication Needs Survey (final).docx
263303	(CMS-10879) Post Conference Event Feedback Request	Form and Instruction	New	Post-Conference Event Feedback Request
262127	Post-Acute Care Training Project (10873)	Form and Instruction	New	Post-Event/Post-Training Survey
261399	Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	Form and Instruction	New	5 - CMS-10827. Mod Guide B - Open Payments Consumer (revised)
261399	Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	Form and Instruction	New	4 - CMS-10827. Mod Guide A - Open Payments Consumer (revised)
261399	Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	Form and Instruction	New	3 - CMS-10827. Consent Form - Open Payments Consumer (revised)
261399	Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	Form and Instruction	New	2 - CMS-10827. Recruitment Guide - Open Payments Consumer (revised)
261362	Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	Form and Instruction	New	CMS-10826.Users-Checked Data (Physicians and Teaching Hospitals) (revised)
261362	Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	Form and Instruction	New	CMS-10826.Health Care Providers (Primary Care and Specialist)
261362	Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	Form and Instruction	New	CMS-10826.Recruitment Guide for Physicians and Other Health Care Providers
261362	Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	Form and Instruction	New	CMS-10826.Recruitment Guide – Teaching Hospital Representatives (revised).docx
261352	Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Focus Groups with Consumers and QHP Issuers (CMS-10869)	Form and Instruction	New	Attachment D: CMS QHP Enrollee Survey QHP Issuer Focus Group Protocol
261352	Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Focus Groups with Consumers and QHP Issuers (CMS-10869)	Form and Instruction	New	Attachment C: CMS QHP Enrollee Survey Consumer Focus Group Protocol
261352	Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Focus Groups with Consumers and QHP Issuers (CMS-10869)	Form and Instruction	New	Attachment B: Consent Forms for Consumers and Issuers
261352	Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Focus Groups with Consumers and QHP Issuers (CMS-10869)	Form and Instruction	New	Attachment A - Recruitment Screeners for Consumer and Issuer Focus Groups
261142	IPRO Nursing Home Collaborator Satisfaction Survey (2023) (CMS-10776)	Form and Instruction	New	IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2023)
261141	IPRO Drug Safety Program Collaborator Survey (2023) (CMS-10770)	Form and Instruction	New	DRAFT IPRO Drug Safety Program Collaborator Survey (2023)
261140	IPRO Community of Care Coalitions Collaborator Survey (2023)(CMS-10771)	Form and Instruction	New	IPRO Partnership for Community Health Coalition Initiative Collaborator Survey (2023)
261138	2023 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	DRAFT IPRO ESRD Network 9 Collaborator Survey (2023)
261138	2023 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	DRAFT IPRO ESRD Network 6 Collaborator Survey (2023)
261138	2023 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	DRAFT IPRO ESRD Network 2 Collaborator Survey (2023)
261138	2023 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	DRAFT IPRO ESRD Network 1 Collaborator Survey (2023)
261081	Oral Health Illustration Survey (CMS-10864)	Form and Instruction	New	Oral Health Survey Plan
261081	Oral Health Illustration Survey (CMS-10864)	Other-Illustrations	New
260502	Patient Subject Matter Expert (PSME) Satisfaction Survey (CMS-10859)	Form and Instruction	New	PSME Satisfaction Survey
259201	J.9 Network Satisfaction Survey (CMS-10841)	Form and Instruction	New	J.9 Customer Satisfaction Survey
257144	Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	Form and Instruction	New	CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007.docx
257144	Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	Form and Instruction	New	CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803
257144	Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	Form and Instruction	New
257143	Replacing Durable Medical Equipment and Prescription Drugs after a Disaster Addressing the Needs of Medicare Beneficiaries Post-training Feedback Survey (CMS-10828)	Form and Instruction	New	Post-Webinar Feedback Survey
257143	Replacing Durable Medical Equipment and Prescription Drugs after a Disaster Addressing the Needs of Medicare Beneficiaries Post-training Feedback Survey (CMS-10828)	Form and Instruction	New
257142	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815)	Form	New	CMS-10815. Call Center Question List.docx
257142	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815)	Form	New
257141	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814)	Form	New	CMS-10814. Written Correspondence Instrument
257141	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814)	Form	New
257140	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813)	Form	New	Web Chat Survey
257140	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813)	Form	New
257139	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)	Form	New	CMS-10812. Audit and Reimbursement - Letter
257139	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)	Form	New	CMS-10812. Audit and Reimbursement - Website
257139	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)	Form	New
257138	Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)	Form and Instruction	New	CMS-10811. Appendix B_Part D Survey Questions FINAL
257138	Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)	Form and Instruction	New	CMS-10811. Appendix A_Part C Survey Questions FINAL
257138	Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)	Form and Instruction	New
257137	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New	Observed Testing Protocol
257137	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New	GADCS Feedback Application
257137	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New
257137	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Instruction	New
257136	IPRO Community of Care Coalitions Collaborator Survey (CMS-10771)	Form and Instruction	New	IPRO Collaborator - Community of Care Coalitions Survey
257136	IPRO Community of Care Coalitions Collaborator Survey (CMS-10771)	Form and Instruction	New
257135	IPRO Drug Safety Program Collaborator Survey (CMS-10770)	Form and Instruction	New	IPRO Collaborator Drug Safety Survey
257135	IPRO Drug Safety Program Collaborator Survey (CMS-10770)	Form and Instruction	New
257134	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New	GADCS Feedback Application
257134	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New
257134	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Instruction	New
257125	IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776)	Form and Instruction	New	Collaborator Survey Nursing Home
257125	IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776)	Form and Instruction	New
257124	Account Manager Satisfaction Survey (CMS-10748)	Form	New	Account Manager Survey
257124	Account Manager Satisfaction Survey (CMS-10748)	Form	New
257123	MACBIS Software Application Electronic Surveys for Users - Webinar Survey Polling Questions (CMS-10719)	Form	New	MACBIS Software Application Electronic Survey
257123	MACBIS Software Application Electronic Surveys for Users - Webinar Survey Polling Questions (CMS-10719)	Form	New
257122	COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766)	Form and Instruction	New	CMS-10766.Instrument for COVID-19 Campaign Page Feedback Survey
257122	COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766)	Form and Instruction	New
257121	Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763)	Form and Instruction	New	CMS-10763.Medical Review Survey - Spanish final
257121	Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763)	Form and Instruction	New	CMS-10763.Medical Review Survey - English final
257121	Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763)	Form and Instruction	New
257120	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762)	Form and Instruction	New	CMS-10762.Final Persistent Mobil Application Feedback Survey (Spanish)
257120	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762)	Form and Instruction	New	Final Persistent Mobile Feedback Survey
257120	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762)	Form and Instruction	New
257118	Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761)	Form and Instruction	New	Final Overall Mobil Application Feedback Survey (Spanish)-final (1)
257118	Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761)	Form and Instruction	New	Final Overall Mobile Feedback Survey-final
257118	Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761)	Form and Instruction	New
257117	Overall Flu Campaign Feedback Survey (CMS-10760)	Form and Instruction	New	Overall Flue Campaign Feedback Survey
257117	Overall Flu Campaign Feedback Survey (CMS-10760)	Form and Instruction	New
257115	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	NW 9 Collaborator Survey
257115	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	NW 6 Collaborator Survey
257115	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	NW 2 Collaborator Survey
257115	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New	NW 1 Collaborator Survey
257115	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	Form and Instruction	New
257114	Account Manager Satisfaction Survey (CMS-10748)	Form	New	Account Manager Satisfaction Survey
257114	Account Manager Satisfaction Survey (CMS-10748)	Form	New
257113	Medicare Casework Customer Satisfaction Survey (CMS-10746)	Form and Instruction	New	Script: Medicare Casework Customer Satisfaction Survey
257113	Medicare Casework Customer Satisfaction Survey (CMS-10746)	Form and Instruction	New
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Marketplace Consumer (Spanish)
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Providers/Suppliers (Spanish)
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: SHIP or Other Assister or Partner (Spanish)
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Medicare Beneficiary (Spanish)
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: All (Webinar)
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: SHIP or Other Assister or Partner
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Marketplace Consumer
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Medicare Beneficiary
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Providers/Suppliers
257112	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New
257111	Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	Form and Instruction	New	Beneficiary Care Management Program Beneficiary Satisfaction Survey_041420
257111	Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	Form and Instruction	New
257110	12th SOW Patient Activation Assessment (CMS-10723)	Form and Instruction	New	CMS-10723.Patient Activation Assessment
257110	12th SOW Patient Activation Assessment (CMS-10723)	Form and Instruction	New
257109	Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726)	Form and Instruction	New	Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020
257109	Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726)	Form and Instruction	New	Attachment B-Consent Forms
257109	Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726)	Form and Instruction	New	Attachment A-Consumer and Issuer Recruitment Language (FG and CT)
257109	Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726)	Form and Instruction	New
257108	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New	CMS-10721.Final Persistent Website Feedback Survey (Spanish)
257108	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New	CMS-10721.Final Persistent Website Feedback Survey
257108	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New	CMS-10721.Final Persistent Portal Feedback Survey (Spanish)
257108	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New	CMS-10721.Final Persistent Portal Feedback Survey
257108	Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	Form and Instruction	New
257107	Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New	CMS-10720.Final Overall Portal Feedback Survey (Spanish)
257107	Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New	CMS-10720.Final Overall Website Feedback Survey (Spanish)
257107	Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New	Final Overall Portal Feedback Survey.docx
257107	Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New	Final Overall Website Feedback Survey
257107	Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	Form and Instruction	New
257106	MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Form	New	MACBIS Software Application Electronic Surveys for Users
257106	MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Form	New
257105	End Stage Renal Disease Grievant Satisfaction Survey	Form and Instruction	New	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey
257105	End Stage Renal Disease Grievant Satisfaction Survey	Form and Instruction	New
257104	Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682)	Form	New	CMS_OCS_TestingQuestions_SitemapTesting.docx
257104	Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682)	Form	New
257103	Medicare.gov Sitewide Qualtrics Survey (CMS-10676)	Form and Instruction	New	Medicare.gov Sitewide Qualtrics Survey
257103	Medicare.gov Sitewide Qualtrics Survey (CMS-10676)	Form and Instruction	New
257102	Medicaregov Medicare Plan Finder Survey	Form and Instruction	New	Medicare.gov - Medicare Plan Finder Survey
257102	Medicaregov Medicare Plan Finder Survey	Form and Instruction	New
257101	CMS.gov User Satisfaction Survey	Form and Instruction	New	CMS.gov User Satisfaction Survey
257101	CMS.gov User Satisfaction Survey	Form and Instruction	New
257100	QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590)	Form and Instruction	New	CMS-10590.QualityNet_User_Survey
257100	QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590)	Form and Instruction	New
257099	Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588)	Form and Instruction	New	Usability Test Script
257099	Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588)	Form and Instruction	New
257098	Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction	New	IVR Phone Script
257098	Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction	New

ICR Details

OMB Control No: 0938-1185	ICR Reference No: 202211-0938-011
Status: Historical Active	Previous ICR Reference No: 201904-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No: OC
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/01/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/29/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2026	36 Months From Approved	02/28/2023
Responses	1,000,000	0	1,000,000
Time Burden (Hours)	60,000	0	50,000
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the agency's programs. This feedback will provide insights into customer or stakeholder perceptions, experiences and expectations, provide an early warning of issues with service, or focus attention on areas where communication, training or changes in operations might improve delivery of products or services. These collections will allow for ongoing, collaborative and actionable communications between the Agency and its customers and stakeholders. It will also allow feedback to contribute directly to the improvement of program management.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 56678	09/15/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 72485	11/25/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 62

table that charts list of burden

IC Title	Form No.	Form Name
(CMS-10879) Post Conference Event Feedback Request	CMS-10879	Post-Conference Event Feedback Request
12th SOW Patient Activation Assessment (CMS-10723)	CMS-10723	CMS-10723.Patient Activation Assessment
2023 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	CMS-10750, CMS-10750, CMS-10750, CMS-10750	DRAFT IPRO ESRD Network 1 Collaborator Survey (2023) ,   DRAFT IPRO ESRD Network 2 Collaborator Survey (2023) ,   DRAFT IPRO ESRD Network 6 Collaborator Survey (2023) ,   DRAFT IPRO ESRD Network 9 Collaborator Survey (2023)
Account Manager Satisfaction Survey (CMS-10748)	CMS-10748	Account Manager Survey
Account Manager Satisfaction Survey (CMS-10748)	CMS-10748	Account Manager Satisfaction Survey
Account Manager Satisfaction Survey (CMS-10748)	CMS-10748, CMS-10748, CMS-10748	PACE Organization Survey ,   Medicare Advantage Organization Survey ,   ACA Issuers Survey
Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	CMS-10729	Beneficiary Care Management Program Beneficiary Satisfaction Survey_041420
Beneficiary Contact Center Customer Satisfaction Survey	CMS-10415	IVR Phone Script
Blue Button 2.0 Developer Experience Customer Satisfaction Survey. (CMS-10924)	CMS-10924	DevEx Survey
Blue Button API Developer Experience Customer Satisfaction Survey. (CMS-10924)	CMS-10924	DevEx Survey.
CCW VRDC Stakeholder Engagement Plan (CMS-10880)	CMS-10880, CMS-10880	VRDC Survey Questions ,   Focus Group Session Moderator Guide Script
CMS-10811. Medicare Parts C and D Improper Payment Measure (IPM) (REVISON)	CMS-10811, CMS-10811	CMS-10811.Appendix A_Part C IPM Survey Questions ,   CMS-10811.Appendix B_Part D IPM Survey Questions
CMS.gov User Satisfaction Survey	CMS-10415	CMS.gov User Satisfaction Survey
COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766)	CMS-10766	CMS-10766.Instrument for COVID-19 Campaign Page Feedback Survey
Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	CMS-10820, CMS-10820	CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803 ,   CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007.docx
Data Collection for Education and Outreach for the Yello System (CMS-10872)	CMS-10872	CMS Applicant Information Collection Form
Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form (CMS-10892)	CMS-10892	Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form
End Stage Renal Disease Grievant Satisfaction Survey	CMS-10415. GenIC#5	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey
Foundational Generative In-Depth Interviews for Medicare Enrollees Seeking Their Medicare Claims Data (CMS-10903)	CMS-10903, CMS-10903, CMS-10903.Attachment B	CMS-10903. Attachment A - Generative In-Depth Interview Guide ,   CMS-10903.Attachment B - Medicare Enrollee Eligibility Screener ,   CMS-10903. Attachment C - Consent form
Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	CMS-10827, CMS-10826, CMS-10826, CMS-10826	2 - CMS-10827. Recruitment Guide - Open Payments Consumer (revised) ,   3 - CMS-10827. Consent Form - Open Payments Consumer (revised) ,   4 - CMS-10827. Mod Guide A - Open Payments Consumer (revised) ,   5 - CMS-10827. Mod Guide B - Open Payments Consumer (revised)
Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	CMS-10826, CMS-10826, CMS-10826, CMS-10826	CMS-10826.Recruitment Guide – Teaching Hospital Representatives (revised).docx ,   CMS-10826.Recruitment Guide for Physicians and Other Health Care Providers ,   CMS-10826.Health Care Providers (Primary Care and Specialist) ,   CMS-10826.Users-Checked Data (Physicians and Teaching Hospitals) (revised)
Health Equity Conference Satisfaction Survey and Interviews (CMS-10890)	CMS-10890	2024 CMS Health Equity Conference Feedback Survey
IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776)	CMS-10776	Collaborator Survey Nursing Home
IPRO Community of Care Coalitions Collaborator Survey (2023)(CMS-10771)	CMS-10771	IPRO Partnership for Community Health Coalition Initiative Collaborator Survey (2023)
IPRO Community of Care Coalitions Collaborator Survey (CMS-10771)	CMS-10771	IPRO Collaborator - Community of Care Coalitions Survey
IPRO Drug Safety Program Collaborator Survey (2023) (CMS-10770)	CMS-10770	DRAFT IPRO Drug Safety Program Collaborator Survey (2023)
IPRO Drug Safety Program Collaborator Survey (CMS-10770)	CMS-10770	IPRO Collaborator Drug Safety Survey
IPRO ESRD Collaborator Satisfaction Survey (CMS-10750)	CMS-10750, CMS-10750, CMS-10750, CMS-10750	NW 1 Collaborator Survey ,   NW 2 Collaborator Survey ,   NW 6 Collaborator Survey ,   NW 9 Collaborator Survey
IPRO Nursing Home Collaborator Satisfaction Survey (2023) (CMS-10776)	CMS-10776	IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2023)
J.9 Network Satisfaction Survey (CMS-10841)	CMS-10841	J.9 Customer Satisfaction Survey
MACBIS Software Application Electronic Surveys for Users (CMS-10719)	CMS-10719	MACBIS Software Application Electronic Surveys for Users
MACBIS Software Application Electronic Surveys for Users - Webinar Survey Polling Questions (CMS-10719)	CMS-10719	MACBIS Software Application Electronic Survey
Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763)	CMS-10763, CMS-10763	CMS-10763.Medical Review Survey - English final ,   CMS-10763.Medical Review Survey - Spanish final
Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721)	CMS-10721, CMS-10721, CMS-10721, CMS-10721	CMS-10721.Final Persistent Portal Feedback Survey ,   CMS-10721.Final Persistent Portal Feedback Survey (Spanish) ,   CMS-10721.Final Persistent Website Feedback Survey ,   CMS-10721.Final Persistent Website Feedback Survey (Spanish)
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)	CMS-10812, CMS-10812	CMS-10812. Audit and Reimbursement - Website ,   CMS-10812. Audit and Reimbursement - Letter
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813)	CMS-10813	Web Chat Survey
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815)	CMS-10815	CMS-10815. Call Center Question List.docx
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814)	CMS-10814	CMS-10814. Written Correspondence Instrument
Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720)	CMS-10720, CMS-10720, CMS-10720, CMS-10720	Final Overall Website Feedback Survey ,   Final Overall Portal Feedback Survey.docx ,   CMS-10720.Final Overall Website Feedback Survey (Spanish) ,   CMS-10720.Final Overall Portal Feedback Survey (Spanish)
Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761)	CMS-10761, CMS-10761	Final Overall Mobile Feedback Survey-final ,   Final Overall Mobil Application Feedback Survey (Spanish)-final (1)
Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762)	CMS-10762, CMS-10762	Final Persistent Mobile Feedback Survey ,   CMS-10762.Final Persistent Mobil Application Feedback Survey (Spanish)
Medicare Casework Customer Satisfaction Survey (CMS-10746)	CMS-10746	Script: Medicare Casework Customer Satisfaction Survey
Medicare Fee-for-Service Provider Communications Preferences Survey (CMS-10876)	CMS-10876	Provider Communication Needs Survey (final).docx
Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)	CMS-10811, CMS-10811	CMS-10811. Appendix A_Part C Survey Questions FINAL ,   CMS-10811. Appendix B_Part D Survey Questions FINAL
Medicare.gov Sitewide Qualtrics Survey (CMS-10676)	CMS-10676	Medicare.gov Sitewide Qualtrics Survey
Medicaregov Medicare Plan Finder Survey	CMS-10415	Medicare.gov - Medicare Plan Finder Survey
Oral Health Illustration Survey (CMS-10864)	CMS-10864	Oral Health Survey Plan
Overall Flu Campaign Feedback Survey (CMS-10760)	CMS-10760	Overall Flue Campaign Feedback Survey
Patient Subject Matter Expert (PSME) Satisfaction Survey (CMS-10859)	CMS-10859	PSME Satisfaction Survey
Post-Acute Care Training Project (10873)	CMS-10873	Post-Event/Post-Training Survey
Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Cognitive Testing	CMS-10889, CMS-10889, CMS-10889, CMS-10889	QHP Cognitive Testing Consumer Consent Form ,   Recruitment Screener ,   Testing Protocol ,   QHP Cognitive Testing Survey
Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Focus Groups with Consumers and QHP Issuers (CMS-10869)	CMS-10869, CMS-10869, CMS-10869, CMS-10869	Attachment A - Recruitment Screeners for Consumer and Issuer Focus Groups ,   Attachment B: Consent Forms for Consumers and Issuers ,   Attachment C: CMS QHP Enrollee Survey Consumer Focus Group Protocol ,   Attachment D: CMS QHP Enrollee Survey QHP Issuer Focus Group Protocol
Quality Improvement of IPPTA Processes and Procedures	CMS-10894, CMS-10894, CMS-10894, CMS-10894, CMS-10894	Preparation: SMEs for IPPTA ,   Data documentation Submission and Sampling ,   Conduct Reviews ,   Observation and Collaboration ,   SBE Closeout
Quality Improvement of IPPTA Processes and Procedures	CMS-10894, CMS-10894, CMS-10894, CMS-10894, CMS-10894	Preparation: SMEs for IPPTA ,   Data documentation Submission and Sampling ,   Conduct Reviews ,   Observation and Collaboration ,   SBE Closeout
QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590)	CMS-10590	CMS-10590.QualityNet_User_Survey
Replacing Durable Medical Equipment and Prescription Drugs after a Disaster Addressing the Needs of Medicare Beneficiaries Post-training Feedback Survey (CMS-10828)	CMS-10828	Post-Webinar Feedback Survey
Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726)	CMS-10726, CMS-10726, CMS10726	Attachment A-Consumer and Issuer Recruitment Language (FG and CT) ,   Attachment B-Consent Forms ,   Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020
Surveying our Customers – Post-activity Evaluation (CMS-10732)	CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732	Customer and Stakeholder Feedback: Providers/Suppliers ,   Customer and Stakeholder Feedback: Medicare Beneficiary ,   Customer and Stakeholder Feedback: Marketplace Consumer ,   Customer and Stakeholder Feedback: SHIP or Other Assister or Partner ,   Customer and Stakeholder Feedback: All (Webinar) ,   Customer and Stakeholder Feedback: Medicare Beneficiary (Spanish) ,   Customer and Stakeholder Feedback: SHIP or Other Assister or Partner (Spanish) ,   Customer and Stakeholder Feedback: Providers/Suppliers (Spanish) ,   Customer and Stakeholder Feedback: Marketplace Consumer (Spanish)
Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682)	CMS-10682	CMS_OCS_TestingQuestions_SitemapTesting.docx
Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588)	CMS-10588	Usability Test Script
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	CMS-10754, CMS-10754	GADCS Feedback Application ,   Observed Testing Protocol
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	CMS-10754	GADCS Feedback Application

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000,000	1,000,000	0	0	0	0
Annual Time Burden (Hours)	60,000	50,000	0	10,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: CMS is requesting that the ICR currently pending OMB approval be revised to include a burden adjustment. Specifically, CMS is requesting to adjust the burden cap from the currently approved 50,000 hours to 60,000 hours, an increase of 10,000 hours. This adjusted burden cap will allow CMS to accommodate both planned upcoming GenICs while also leaving a burden available for possible submission of ad hoc or administrative priority GenICs.

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Annual Cost to Federal Government: $250,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/29/2022

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