Information Collection

Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726)

IC 257109 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726)	Form and Instruction
CMS-10726 Attachment A-Consumer and Issuer Recruitment Language (F Attachment A-Consumer and Issuer Recruitment Language (FG and CT).docx	Form and Instruction
CMS-10726 Attachment A-Consumer and Issuer Recruitment Language (F Attachment A-Consumer and Issuer Recruitment Language (FG and CT).docx	Form and Instruction
CMS-10726 Attachment B-Consent Forms Attachment B-Consent Forms.docx	Form and Instruction
CMS-10726 Attachment B-Consent Forms Attachment B-Consent Forms.docx	Form and Instruction
CMS10726 Attachment C-Detailed Description of Focus Groups and Co Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020.docx	Form and Instruction
CMS10726 Attachment C-Detailed Description of Focus Groups and Co Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020.docx	Form and Instruction
CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN.docx CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN	IC Document
CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN.docx CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10726	Attachment A-Consumer and Issuer Recruitment Language (FG and CT)	Attachment A-Consumer and Issuer Recruitment Language (FG and CT).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10726	Attachment B-Consent Forms	Attachment B-Consent Forms.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS10726	Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020	Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	40
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN	CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN.docx	11/25/2022

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