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Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version
Implementation of the Medicare Prescription Drug Plan (PDP) and Medicare Advantage (MA) Plan Disenrollment Reasons Survey (CMS-10316)
OMB: 0938-1113
IC ID: 194737
OMB.report
HHS/CMS
OMB 0938-1113
ICR 202407-0938-010
IC 194737
( )
Documents and Forms
Document Name
Document Type
Form CMS-10316
Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version
Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan
Attachment V_Survey_PDP_508Compliant_v2.pdf
Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Spanish)
2025_PDP_508 compliant_Spanish_06-26-2024.pdf
Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Chinese)
2025 PDP Survey_508_compliant_Traditional Chinese_06-18-25.pdf
Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Vietnamese)
2025 PDP Survey_Vietnamese_06-19-2025_508compliant.pdf
Form
Attachment I_Prenote_clean_12.15.2023_.docx
PDP prenotification letter
IC Document
Attachment II_Wave1_Cover_Letter_clean_12.15.2023_.docx
Wave 1 cover letter
IC Document
Attachment III_Wave2_Cover_Letter_clean.docx
Wave 2 cover letter
IC Document
Attachment VII_Year-to-Year Variability of Disenrollment Reason Scores_.docx
Memo on year-to-year variability
IC Document
Prenote_508 compliant_Traditional Chinese_06-30-24.pdf
Prenote_Traditional Chinese
IC Document
Wave1_Cover_Letter_508 compliant_Traditional Chinese_06-30-24.pdf
Wave1_Cover_Letter_Traditional Chinese
IC Document
Wave2_Cover_Letter_clean_508compliant - Traditional Chinese_06-18-25.pdf
Wave2_Cover_Letter_clean - Traditional Chinese
IC Document
PDP Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf
PDP Disenrollment Survey Crosswalk_
IC Document
2025 Prenote_Vietnamese_07.01.2025_508compliant.pdf
Prenote_Vietnamese
IC Document
2025 Wave1_Cover_Letter_Vietnamese_06-19-2025_508compliant.pdf
Wave1_Cover_Letter_Vietnamese
IC Document
2025_Wave2_Cover_Letter_Vietnamese_06-19-2025_508compliant.pdf
Wave2_Cover_Letter_Vietnamese
IC Document
Information Collection (IC) Details
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