Information Collection

Customer Experience Surveys (CMS-10833 revised)

IC 271820 under ICR 202405-0938-010 · OMB 0938-1397.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10833 Service Center Customer Experience Survey Customer Experience Surveys (CMS-10833 revised)	Form and Instruction
CMS-10833 Service Center Customer Experience Survey CMS-10833 Service Center Customer Experience Survey with LOB Questions.docx	Form and Instruction
CMS-10833 - Customer Effort Scoring Revised Clean Copy.docx CMS-10833 Supporting Statement	IC Document
PRA_Disclosure.pdf Disclosure Statement	IC Document

IC Title:

Agency IC Tracking Number:

CCSQ

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-10833				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,800

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	4,800	4,800
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10833 Supporting Statement		10/23/2024
Disclosure Statement		10/23/2024

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

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