Information Collection

Overall Flu Campaign Feedback Survey (CMS-10760)

IC 257117 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10760 Overall Flu Campaign Feedback Survey (CMS-10760)	Form and Instruction
CMS-10760 Overall Flue Campaign Feedback Survey CMS-10760.Flu Campaign Page Feedback Survey.docx	Form and Instruction
CMS-10760 Overall Flue Campaign Feedback Survey CMS-10760.Flu Campaign Page Feedback Survey.docx	Form and Instruction
CMS-10760.Flu Survey Fast Track Submission.docx CMS-10760.Flu Survey Fast Track Submission	IC Document
CMS-10760.Flu Survey Fast Track Submission.docx CMS-10760.Flu Survey Fast Track Submission	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-10760	Overall Flue Campaign Feedback Survey	CMS-10760.Flu Campaign Page Feedback Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,872

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	4,872	4,872
Annual IC Time Burden (Hours)	81	81
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10760.Flu Survey Fast Track Submission	CMS-10760.Flu Survey Fast Track Submission.docx	11/25/2022

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