Information Collection

[Medicaid] CMS-10911 (Revision): Medicaid.gov Static Feedback

IC 280043 under ICR 202609-0938-011 · OMB 0938-1382.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10911 Medicaid.gov Static Feedback Tool [Medicaid] CMS-10911 (Revision): Medicaid.gov Static Feedback	Form and Instruction
CMS-10911 Medicaid.gov Static Feedback Tool CMS 10911 - UAT Medicaid Feedback Tool.xlsx	Form and Instruction
CMS-10911 - GenIC for Improving Customer Experience (2026 version 4).docx Generic Supporting Statement	IC Document
CMS-10911 - Supporting Statement Part B_2026.docx Supporting Statement B	IC Document
CMS10911 Crosswalk - Medicaid.gov Feedback Tool.xlsx Survey: Crosswalk	IC Document
CMS 10911 - Screenshots - REDLINE Current Medicaid Feedback Tool_4-2026.docx Survey: Redline Screenshots	IC Document

IC Title:

Agency IC Tracking Number:

CMCS

IC Status: Modified

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-10911				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
	Requested	Previously Approved
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		04/21/2026
Supporting Statement B		04/21/2026
Survey: Crosswalk		04/21/2026
Survey: Redline Screenshots		04/21/2026

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

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