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

ICR 202211-0938-011

OMB: 0938-1185

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10820 Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820) Form and Instruction	New
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
Form CMS-10815 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815) Form	New
Form CMS-10814 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814) Form	New
Form CMS-10813 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813) Form	New
Form CMS-10812 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812) Form	New
Form CMS-10811 Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811) Form and Instruction	New
Form CMS-10754 User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754) Form and Instruction	New
Form CMS-10771 IPRO Community of Care Coalitions Collaborator Survey (CMS-10771) Form and Instruction	New
Form CMS-10770 IPRO Drug Safety Program Collaborator Survey (CMS-10770) Form and Instruction	New
Form CMS-10754 User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754) Form and Instruction	New
Form CMS-10776 IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776) Form and Instruction	New
Form CMS-10748 Account Manager Satisfaction Survey (CMS-10748) Form	New
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users - Webinar Survey Polling Questions (CMS-10719) Form	New
Form CMS-10766 COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766) Form and Instruction	New
Form CMS-10763 Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763) Form and Instruction	New
Form CMS-10762 Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762) Form and Instruction	New
Form CMS-10761 Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761) Form and Instruction	New
Form CMS-10760 Overall Flu Campaign Feedback Survey (CMS-10760) Form and Instruction	New
Form CMS-10750 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750) Form and Instruction	New
Form CMS-10748 Account Manager Satisfaction Survey (CMS-10748) Form	New
Form CMS-10746 Medicare Casework Customer Satisfaction Survey (CMS-10746) Form and Instruction	New
Form CMS-10732 Surveying our Customers – Post-activity Evaluation (CMS-10732) Form	New
Form CMS-10729 Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729) Form and Instruction	New
Form CMS-10723 12th SOW Patient Activation Assessment (CMS-10723) Form and Instruction	New
Form CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726) Form and Instruction	New
Form CMS-10721 Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721) Form and Instruction	New
Form CMS-10720 Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720) Form and Instruction	New
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users (CMS-10719) Form	New
Form CMS-10415. GenIC#5 End Stage Renal Disease Grievant Satisfaction Survey Form and Instruction	New
Form CMS-10682 Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682) Form	New
Form CMS-10676 Medicare.gov Sitewide Qualtrics Survey (CMS-10676) Form and Instruction	New
Form CMS-10415 Medicaregov Medicare Plan Finder Survey Form and Instruction	New
Form CMS-10415 CMS.gov User Satisfaction Survey Form and Instruction	New
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
Form CMS-10588 Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588) Form and Instruction	New
Form CMS-10415 Beneficiary Contact Center Customer Satisfaction Survey Form and Instruction	New
CMS-10415_Supporting Statement A - 2022.docx Supporting Statement A	2022-11-29
CMS-10415_Supporting_Statement_Part_B.docx Supporting Statement B	2022-11-28

IC Document Collections

IC ID	Document Title	Status
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
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
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
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
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
257134	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754) Form and Instruction	New
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
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
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
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
257115	IPRO ESRD Collaborator Satisfaction Survey (CMS-10750) Form and Instruction	New
257114	Account Manager Satisfaction Survey (CMS-10748) Form	New
257113	Medicare Casework Customer Satisfaction Survey (CMS-10746) Form and Instruction	New
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
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
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
257106	MACBIS Software Application Electronic Surveys for Users (CMS-10719) Form	New
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
257103	Medicare.gov Sitewide Qualtrics Survey (CMS-10676) Form and Instruction	New
257102	Medicaregov Medicare Plan Finder Survey Form and Instruction	New
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
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