Information Collection

[Medicaid] Medicaid.gov Customer Feedback Survey (CMS-10909)

IC 270188 under ICR 202402-0938-008 · OMB 0938-1382.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10909 Medicaid.gov Customer Feedback Survey [Medicaid] Medicaid.gov Customer Feedback Survey (CMS-10909)	Form and Instruction
CMS-10909 Medicaid.gov Customer Feedback Survey CMS-10909 - Medicaid.gov Survey (2024 version 2).xlsx	Form and Instruction
CMS-10909 - Generic Clearance Request Under Under OMB Circular A11 Section 280 (2024 version 2).docx Generic Supporting Statement	IC Document
CMS-10909 - Supporting Statement B (2024 version 2).docx Supporting Statement B	IC Document
CMS-10909 - Medicaid.gov Survey (2024 version 1) REDLINE.xlsx REDLINE Medicaid.gov Customer Feedback Survey	IC Document
CMS-10909_OMB 0938-1382_Medicaid.gov Popup Survey 8 22 24.docx ICR Template 8 22 2024	IC Document

IC Title:

Agency IC Tracking Number:

CMCS

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-10909				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,643

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	2,643	2,643
Annual IC Time Burden (Hours)	88	88
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		08/16/2024
Supporting Statement B		08/16/2024
REDLINE Medicaid.gov Customer Feedback Survey		08/16/2024
ICR Template 8 22 2024		08/22/2024

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

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