Information Collection

J.9 Network Satisfaction Survey (CMS-10841)

IC 259201 under ICR 202211-0938-011 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10841 J.9 Customer Satisfaction Survey J.9 Network Satisfaction Survey (CMS-10841)	Form and Instruction
CMS-10841 J.9 Customer Satisfaction Survey CMS- 10841 J.9 Network Customer Satisfaction Survey_PRA disclosure.docx	Form and Instruction
CMS-10841 J.9 Network Satisfaction Survey_Generic_Clearance_Submission (v4).docx CMS-10841 Supporting Statement	IC Document

IC Title:

J.9 Network Satisfaction Survey (CMS-10841)

Agency IC Tracking Number:

CCSQ

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-10841				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,794

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,794	7,794
Annual IC Time Burden (Hours)	257	257
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10841 Supporting Statement		03/17/2023

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

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