Information Collection

COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766)

IC 257122 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10766 COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766)	Form and Instruction
CMS-10766 CMS-10766.Instrument for COVID-19 Campaign Page Feedback CMS-10766.Instrument for COVID-19 Campaign Page Feedback Survey.docx	Form and Instruction
CMS-10766 CMS-10766.Instrument for COVID-19 Campaign Page Feedback CMS-10766.Instrument for COVID-19 Campaign Page Feedback Survey.docx	Form and Instruction
CMS-10766.COVID_19 Campaign Survey Fast Track.docx CMS-10766.COVID_19 Campaign Survey Fast Track Request	IC Document
CMS-10766.COVID_19 Campaign Survey Fast Track.docx CMS-10766.COVID_19 Campaign Survey Fast Track Request	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-10766	CMS-10766.Instrument for COVID-19 Campaign Page Feedback Survey	CMS-10766.Instrument for COVID-19 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: 100 %

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-10766.COVID_19 Campaign Survey Fast Track Request	CMS-10766.COVID_19 Campaign Survey Fast Track.docx	11/25/2022

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