Information Collection

Beneficiary Contact Center Customer Satisfaction Survey

IC 257098 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

IC Status: New

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.