Surveying our Customers – Post-activity Evaluation (CMS-10732)

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

OMB: 0938-1185

IC ID: 257112

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Surveying our Customers – Post-activity Evaluation (CMS-10732)
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers LEA Engagement Feedback Questionnaire - PROVIDERS_a.pdf No   Fillable Fileable
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary LEA Engagement Feedback Questionnaire - MEDICARE BENEFICIARIES_a.pdf No   Fillable Fileable
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer LEA Engagement Feedback Questionnaire - MARKETPLACE CONSUMERS_a.pdf No   Fillable Fileable
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner LEA Engagement Feedback Questionnaire - COUNSELORS ASSISTERS_a.pdf No   Fillable Fileable
Form CMS-10732 Customer and Stakeholder Feedback: All (Webinar) LEA Engagement Eval from Webinar Hyperlink (version 3).docx Yes Yes Fillable Fileable
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary (Spanish) LEAquestionaire-beneficiariesSpan-508_a.pdf No   Fillable Fileable
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner (Spanish) LEAquestionaire-counselorsSpan-508_a.pdf No   Fillable Fileable
Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers (Spanish) LEAquestionaire-providersSpan-508_a.pdf No   Fillable Fileable
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer (Spanish) LEAquestionaire-marketplaceSpan-508_a.pdf No   Fillable Fileable

Health Health Care Services

 

22,320 0
   
Individuals or Households
 
   50 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 22,320 0 22,320 0 0 0
Annual IC Time Burden (Hours) 1,116 0 1,116 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-10732 - LEA Fast Track Supporting Statement (version 3) CMS-10732 - LEA Fast Track Supporting Statement (version 3).docx 11/25/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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