Information Collection

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

IC 257112 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10732 Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form
CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers LEA Engagement Feedback Questionnaire - PROVIDERS_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers LEA Engagement Feedback Questionnaire - PROVIDERS_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary LEA Engagement Feedback Questionnaire - MEDICARE BENEFICIARIES_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary LEA Engagement Feedback Questionnaire - MEDICARE BENEFICIARIES_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer LEA Engagement Feedback Questionnaire - MARKETPLACE CONSUMERS_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer LEA Engagement Feedback Questionnaire - MARKETPLACE CONSUMERS_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assiste LEA Engagement Feedback Questionnaire - COUNSELORS ASSISTERS_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assiste LEA Engagement Feedback Questionnaire - COUNSELORS ASSISTERS_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: All (Webinar) LEA Engagement Eval from Webinar Hyperlink (version 3).docx	Form
CMS-10732 Customer and Stakeholder Feedback: All (Webinar) LEA Engagement Eval from Webinar Hyperlink (version 3).docx	Form
CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary LEAquestionaire-beneficiariesSpan-508_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary LEAquestionaire-beneficiariesSpan-508_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assiste LEAquestionaire-counselorsSpan-508_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assiste LEAquestionaire-counselorsSpan-508_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers ( LEAquestionaire-providersSpan-508_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers ( LEAquestionaire-providersSpan-508_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer LEAquestionaire-marketplaceSpan-508_a.pdf	Form
CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer LEAquestionaire-marketplaceSpan-508_a.pdf	Form
CMS-10732 - LEA Fast Track Supporting Statement (version 3).docx CMS-10732 - LEA Fast Track Supporting Statement (version 3)	IC Document
CMS-10732 - LEA Fast Track Supporting Statement (version 3).docx CMS-10732 - LEA Fast Track Supporting Statement (version 3)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

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	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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,320

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	22,320	22,320
Annual IC Time Burden (Hours)	1,116	1,116
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.