Information Collection

iQIES Post-Launch Sentiment Survey (CMS-10926)

IC 275429 under ICR 202405-0938-010 · OMB 0938-1397.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10926 Qualtrics Survey - QEM iQIES Post-Launch Sentiment Survey (CMS-10926)	Form
Qualtrics Survey instructions_ QEM .pdf	Instruction
CMS-10926 Qualtrics Survey - QEM Qualtrics Survey _ Qualtrics Experience Management.pdf	Form
CMS-10926 ICRTEM_1.final.docx Supporting 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	CMS-10926				Yes	Yes	Fillable Fileable
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	200	200
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement		05/22/2025

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

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