Information Collection

CMS-10710.GenIC#5 - Medicare.gov Web Sat Survey (A11 Section 280)

IC 262620 under ICR 202309-0938-019 · OMB 0938-1382.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1382 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10710.GenIC#5 CMS-10710.GenIC#5 - Medicare.gov Web Sat Survey (A11 Section 280)	Form and Instruction
CMS-10710.GenIC#5 CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 2 CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280) (30-day).pdf	Form and Instruction
CMS-10710.GenIC#5 CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 2 CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280) (30-day).pdf	Form and Instruction
CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280) (30-day).docx CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280) (30-day)	IC Document
CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280) (30-day).docx CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280) (30-day)	IC Document

IC Title:

CMS-10710.GenIC#5 - Medicare.gov Web Sat Survey (A11 Section 280)

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-10710.GenIC#5	CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280)	CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280) (30-day).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 360,000

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	360,000	360,000
Annual IC Time Burden (Hours)	24,000	24,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280) (30-day)	CMS-10710#5 - Medicare.gov Web Sat Survey (A11 Section 280) (30-day).docx	09/30/2023

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