Information Collection

Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version

IC 194737 under ICR 202407-0938-010 · OMB 0938-1113.

Documents and Forms

Documents and forms in this information collection
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 Attachment V_Survey_PDP_508Compliant_v2.pdf	Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Span 2025_PDP_508 compliant_Spanish_06-26-2024.pdf	Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Span 2025_PDP_508 compliant_Spanish_06-26-2024.pdf	Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Chin 2025 PDP Survey_508_compliant_Traditional Chinese_06-18-25.pdf	Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Chin 2025 PDP Survey_508_compliant_Traditional Chinese_06-18-25.pdf	Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Viet 2025 PDP Survey_Vietnamese_06-19-2025_508compliant.pdf	Form
CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan (Viet 2025 PDP Survey_Vietnamese_06-19-2025_508compliant.pdf	Form
Attachment I_Prenote_clean_12.15.2023_.docx PDP prenotification letter	IC Document
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 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 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
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
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
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
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
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 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 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
2025_Wave2_Cover_Letter_Vietnamese_06-19-2025_508compliant.pdf Wave2_Cover_Letter_Vietnamese	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Disenrollee Survey, Stand Alone Prescription Drug Plan (PDP) Version

Agency IC Tracking Number:

CM-CPC

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.156

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	CMS-10316	Medicare Disenrollee Survey Prescriptopn Drug Plan	Attachment V_Survey_PDP_508Compliant_v2.pdf	No	Fillable Printable
Form	CMS-10316	Medicare Disenrollee Survey Prescriptopn Drug Plan (Spanish)	2025_PDP_508 compliant_Spanish_06-26-2024.pdf	No	Fillable Printable
Form	CMS-10316	Medicare Disenrollee Survey Prescriptopn Drug Plan (Chinese)	2025 PDP Survey_508_compliant_Traditional Chinese_06-18-25.pdf	No	Fillable Printable
Form	CMS-10316	Medicare Disenrollee Survey Prescriptopn Drug Plan (Vietnamese)	2025 PDP Survey_Vietnamese_06-19-2025_508compliant.pdf	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,005

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,005	255	3,750
Annual IC Time Burden (Hours)	641	-34	675
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PDP prenotification letter	Attachment I_Prenote_clean_12.15.2023_.docx	07/12/2024
Wave 1 cover letter	Attachment II_Wave1_Cover_Letter_clean_12.15.2023_.docx	07/12/2024
Wave 2 cover letter	Attachment III_Wave2_Cover_Letter_clean.docx	07/12/2024
Memo on year-to-year variability	Attachment VII_Year-to-Year Variability of Disenrollment Reason Scores_.docx	07/12/2024
Prenote_Traditional Chinese	Prenote_508 compliant_Traditional Chinese_06-30-24.pdf	07/12/2024
Wave1_Cover_Letter_Traditional Chinese	Wave1_Cover_Letter_508 compliant_Traditional Chinese_06-30-24.pdf	07/12/2024
Wave2_Cover_Letter_clean - Traditional Chinese	Wave2_Cover_Letter_clean_508compliant - Traditional Chinese_06-18-25.pdf	07/12/2024
PDP Disenrollment Survey Crosswalk_	PDP Disenrollment Survey crosswalk_OMB_01.19.2024_508compliant.pdf	07/12/2024
Prenote_Vietnamese	2025 Prenote_Vietnamese_07.01.2025_508compliant.pdf	07/12/2024
Wave1_Cover_Letter_Vietnamese	2025 Wave1_Cover_Letter_Vietnamese_06-19-2025_508compliant.pdf	07/12/2024
Wave2_Cover_Letter_Vietnamese	2025_Wave2_Cover_Letter_Vietnamese_06-19-2025_508compliant.pdf	07/12/2024

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