Information Collection

[Medicaid] CMS-10909 (Revision): Medicaid.gov Pop-up Survey

IC 280632 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 Pop-up Survey [Medicaid] CMS-10909 (Revision): Medicaid.gov Pop-up Survey	Form and Instruction
CMS-10909 Medicaid.gov Pop-up Survey CMS 10909 - UAT Medicaid.gov Pop-up Survey Desktop and Mobile.xlsx	Form and Instruction
CMS-10909 - GenIC for Improving Customer Experience (2026 version 5).docx Generic Supporting Statement	IC Document
CMS-10909 - Supporting Statement Part B (2026 version 2).docx Supporting Statement B	IC Document
CMS10909 Crosswalk - Medicaid.gov Pop-up Survey Desktop and Mobile.xlsx Crosswalk: Medicaid.gov Pop-up Survey	IC Document
CMS 10909 - Screenshots - REDLINE Medicaid.gov Desktop and Mobile Survey_5-2026.docx Redline: Medicaid.gov Pop-up Survey	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: 1

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	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		05/28/2026
Supporting Statement B		05/28/2026
Crosswalk: Medicaid.gov Pop-up Survey		05/28/2026
Redline: Medicaid.gov Pop-up Survey		05/28/2026

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

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