Beneficiary Contact Center Customer Satisfaction Survey

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

Documents and Forms

Document Name Document Type
Form CMS-10415 Beneficiary Contact Center Customer Satisfaction Survey Form and Instruction
CMS-10415 IVR Phone Script IVR Phone Script.docx Form and Instruction
CMS-10415 IVR Phone Script IVR Phone Script.docx Form and Instruction
IVR Survey Submission Form.docx Generic Submission Template for IVR Survey IC Document
IVR Survey Submission Form.docx Generic Submission Template for IVR Survey IC Document

Information Collection (IC) Details

IC Title:	Beneficiary Contact Center Customer Satisfaction Survey	Agency IC Tracking Number:	OC

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10415	IVR Phone Script	IVR Phone Script.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 145,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	145,000	145,000
Annual IC Time Burden (Hours)	5,776	5,776
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Submission Template for IVR Survey	IVR Survey Submission Form.docx	11/25/2022

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