Information Collection

[Medicaid] Insure Kids Now Customer Feedback Survey (CMS-10910)

IC 270189 under ICR 202402-0938-008 · OMB 0938-1382.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10910 Insure Kids Now Customer Feedback Survey [Medicaid] Insure Kids Now Customer Feedback Survey (CMS-10910)	Form and Instruction
CMS-10910 Insure Kids Now Customer Feedback Survey CMS-10910 - Insure Kids Now Survey (2024 version 2).xlsx	Form and Instruction
CMS-10910 - Generic Clearance Request Under OMB Circular A11 Section 280 (2024 version 2).docx Generic Clearance Request for Approval	IC Document
CMS-10910 - Supporting Statement Part B (2024 version 2).docx Supporting Statement B	IC Document
CMS-10910 - Insure Kids Now Survey (2024 version 1) REDLINE.xlsx REDLINE Insure Kids Now Customer Feedback Survey	IC Document
CMS-10910_OMB 0938-1382_InsureKidsNow Popup Survey 8 22 24.docx ICR Template UPDATED 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-10910				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	100	100
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Clearance Request for Approval		08/16/2024
Supporting Statement B		08/16/2024
REDLINE Insure Kids Now Customer Feedback Survey		08/16/2024
ICR Template UPDATED 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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