Information Collection

Salesforce Customer Relationship Management Satisfaction Survey (CMS-10966)

IC 280700 under ICR 202609-0938-011 · OMB 0938-1382.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10966 Proposed Qualtrics Survey Script Salesforce Customer Relationship Management Satisfaction Survey (CMS-10966)	Form and Instruction
CMS-10966 Proposed Qualtrics Survey Script Qualtrics Survey Script (v2)_clean.docx	Form and Instruction
A11 Section 280_CMS-10966 Fast Track Supporting Statement.docx A11 Section 280_ Supporting Statement	IC Document
Qualtrics Survey Script (v2)_redline.pdf Track Change - Qualtrics Survey Script	IC Document
CMS-10966_Non-substantive change memo.docx Non-substantive memo	IC Document

IC Title:

Agency IC Tracking Number:

OEDA-DIDG

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-10966				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,000	0	10,000
Annual IC Time Burden (Hours)	500	450	50
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
A11 Section 280_ Supporting Statement		09/11/2026
Track Change - Qualtrics Survey Script		09/11/2026
Non-substantive memo		09/11/2026

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

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