Information Collection

[Medicaid] Medicaid.gov Feedback Survey (CMS-10911)

IC 270190 under ICR 202402-0938-008 · OMB 0938-1382.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10911 Medicaid.gov Feedback Survey [Medicaid] Medicaid.gov Feedback Survey (CMS-10911)	Form and Instruction
Form CMS-10911 Medicaid.gov Always On Feedback Survey [Medicaid] Medicaid.gov Feedback Survey (CMS-10911)	Form
CMS-10911 Medicaid.gov Feedback Survey CMS-10911 - Medicaid.gov Feedback Survey (2024 version 2).xlsx	Form and Instruction
CMS-10911 Medicaid.gov Always On Feedback Survey CMS-10911 - Medicaid.gov Feedback Survey (2024 version 3).xlsx	Form
CMS-10911 - Generic Clearance Request Under OMB Circular A11 Section 280 (2024 version 2).docx Request for Generic Clearance	IC Document
CMS-10911 - Supporting Statement Part B (2024 version 1).docx Supporting Statement B	IC Document
CMS-10911 - Medicaid.gov Feedback Survey (2024 version 1) REDLINE.xlsx REDLINE Medicaid.gov Feedback Survey	IC Document
OMB 0938-1382_Medicaid.gov Static 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-10911				Yes	Yes	Fillable Fileable
Form	CMS-10911				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,300

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	1,300	1,300
Annual IC Time Burden (Hours)	22	22
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Generic Clearance		08/16/2024
Supporting Statement B		08/16/2024
REDLINE Medicaid.gov 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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