Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10892 Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form	Form and Instruction	New	Available
Form CMS-10748 ACA Issuers Survey	Form	New	Available
Form CMS-10748 Medicare Advantage Organization Survey	Form	New	Available
Form CMS-10748 PACE Organization Survey	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer (Spanish)	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers (Spanish)	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner (Spanish)	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary (Spanish)	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: All (Webinar)	Form and Instruction	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary	Form	New	Available
Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers	Form	New	Available
Form CMS-10924 DevEx Survey (2026)	Form and Instruction	New	Available
Form CMS-10719 MACBIS Software Application Electronic Survey	Form	New	Available
Form CMS-10872 CMS Applicant Information Collection Form	Form and Instruction	New	Available
Form CMS-10894 SBE Closeout	Form and Instruction	New	Available
Form CMS-10894 Observation and Collaboration	Form and Instruction	New	Available
Form CMS-10894 Conduct Reviews	Form and Instruction	New	Available
Form CMS-10894 Data documentation Submission and Sampling	Form and Instruction	New	Available
Form CMS-10894 Preparation: SBEs for IPPTA	Form and Instruction	New	Available
Form CMS-10880 Focus Group Session Moderator Guide Script	Form and Instruction	New	Available
Form CMS-10880 VRDC Survey Questions	Form and Instruction	New	Available
Form CMS-10879 Post-Conference Event Feedback Request	Form and Instruction	New	Available
Form CMS-10873 Post-Event/Post-Training Survey	Form and Instruction	New	Available
Form CMS-10827 5 - CMS-10827. Mod Guide B - Open Payments Consumer (revised)	Form and Instruction	New	Available
Form CMS-10827 CMS-10827. Mod Guide A - Open Payments Consumer (revised)	Form and Instruction	New	Available
Form CMS-10827 3 - CMS-10827. Consent Form - Open Payments Consumer (revised)	Form and Instruction	New	Available
Form CMS-10827 2 - CMS-10827. Recruitment Guide - Open Payments Consumer (revised)	Form and Instruction	New	Available
Form CMS-10826 CMS-10826.Users-Checked Data (Physicians and Teaching Hospitals) (revised)	Form and Instruction	New	Available
Form CMS-10826 CMS-10826.Health Care Providers (Primary Care and Specialist)	Form and Instruction	New	Available
Form CMS-10826 CMS-10826.Recruitment Guide for Physicians and Other Health Care Providers	Form and Instruction	New	Available
Form CMS-10826 CMS-10826.Recruitment Guide – Teaching Hospital Representatives	Form and Instruction	New	Available
Form CMS-10864 Oral Health Survey Plan	Form and Instruction	New	Available
Form CMS-10859 PSME Satisfaction Survey	Form and Instruction	New	Available
Form CMS-10841 J.9 Customer Satisfaction Survey	Form and Instruction	New	Available
Form CMS-10820 CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007	Form and Instruction	New	Available
Form CMS-10820 CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803	Form and Instruction	New	Available
Form CMS-10754 Observed Testing Protocol	Form and Instruction	New	Available
Form CMS-10754 GADCS Feedback Application	Form and Instruction	New	Available
Form CMS-10754 GADCS Draft Feedback Clean	Form and Instruction	New	Available
Form CMS-10748 Account Manager Satisfaction Survey	Form	New	Available
Form CMS-10729 CMS-10729 Beneficiary Care Management Program Beneficiary Satisfaction Survey	Form and Instruction	New	Available
Form CMS-10723 CMS-10723.Patient Activation Assessment	Form and Instruction	New	Available
Form CMS-10719 MACBIS Software Application Electronic Survey	Form	New	Available
Form CMS-10415 End Stage Renal Disease (ESRD) Grievant Satisfaction Survey	Form and Instruction	New	Available
Form CMS-10676 CMS-10676.Medicare.gov Sitewide Qualtrics Survey	Form and Instruction	New	Available
Form CMS-10415 CMS-10415. Fast Track Medicaregov - Medicare Plan Finder Survey	Form and Instruction	New	Available
Form CMS-10415 CMS-10415.Fast Track CMSgov Survey (2)	Form and Instruction	New	Available
Form CMS-10415 IVR Phone Script	Form and Instruction	New	Available
Fast Track - Blank Template.docx	Supplementary Document	Uploaded 2026-10-14	Available
CMS-10415_Supporting_Statement_Part_B.docx	Supporting Statement B	Uploaded 2026-10-14	Available
(0938-1185) CMS-10415.Supporting Statement A (30-day).docx	Supporting Statement A	Uploaded 2026-10-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
283067	Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form (CMS-10892)	Form and Instruction	New	Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form
283062	Account Manager Satisfaction Survey (CMS-10748)	Other-Other-Emails to Plan Sponsors	New
283062	Account Manager Satisfaction Survey (CMS-10748)	Form	New	ACA Issuers Survey
283062	Account Manager Satisfaction Survey (CMS-10748)	Form	New	Medicare Advantage Organization Survey
283062	Account Manager Satisfaction Survey (CMS-10748)	Form	New	PACE Organization Survey
283061	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Marketplace Consumer (Spanish)
283061	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Providers/Suppliers (Spanish)
283061	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: SHIP or Other Assister or Partner (Spanish)
283061	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Medicare Beneficiary (Spanish)
283061	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form and Instruction	New	Customer and Stakeholder Feedback: All (Webinar)
283061	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: SHIP or Other Assister or Partner
283061	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Marketplace Consumer
283061	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Medicare Beneficiary
283061	Surveying our Customers – Post-activity Evaluation (CMS-10732)	Form	New	Customer and Stakeholder Feedback: Providers/Suppliers
283059	Blue Button 2.0 Developer Experience Customer Satisfaction Survey (CMS-10924)	Form and Instruction	New	DevEx Survey (2026)
283058	MACBIS Software Application Electronic Surveys for Users -Webinar Survey Polling Questions (CMS-10719)	Form	New	MACBIS Software Application Electronic Survey
283056	Data Collection for Education and Outreach for the Yello System (CMS-10872)	Form and Instruction	New	CMS Applicant Information Collection Form
283055	Quality Improvement of IPPTA Processes and Procedures (CMS-10894)	Form and Instruction	New	SBE Closeout
283055	Quality Improvement of IPPTA Processes and Procedures (CMS-10894)	Form and Instruction	New	Observation and Collaboration
283055	Quality Improvement of IPPTA Processes and Procedures (CMS-10894)	Form and Instruction	New	Conduct Reviews
283055	Quality Improvement of IPPTA Processes and Procedures (CMS-10894)	Form and Instruction	New	Data documentation Submission and Sampling
283055	Quality Improvement of IPPTA Processes and Procedures (CMS-10894)	Form and Instruction	New	Preparation: SBEs for IPPTA
283054	CCW VRDC Stakeholder Engagement Plan (CMS-10880)	Form and Instruction	New	Focus Group Session Moderator Guide Script
283054	CCW VRDC Stakeholder Engagement Plan (CMS-10880)	Form and Instruction	New	VRDC Survey Questions
283053	Post Conference Event Feedback Request (CMS-10879)	Form and Instruction	New	Post-Conference Event Feedback Request
283052	Post-Acute Care Training Project (10873)	Form and Instruction	New	Post-Event/Post-Training Survey
283017	Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	Form and Instruction	New	5 - CMS-10827. Mod Guide B - Open Payments Consumer (revised)
283017	Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	Form and Instruction	New	CMS-10827. Mod Guide A - Open Payments Consumer (revised)
283017	Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	Form and Instruction	New	3 - CMS-10827. Consent Form - Open Payments Consumer (revised)
283017	Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	Form and Instruction	New	2 - CMS-10827. Recruitment Guide - Open Payments Consumer (revised)
283015	Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	Form and Instruction	New	CMS-10826.Users-Checked Data (Physicians and Teaching Hospitals) (revised)
283015	Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	Form and Instruction	New	CMS-10826.Health Care Providers (Primary Care and Specialist)
283015	Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	Form and Instruction	New	CMS-10826.Recruitment Guide for Physicians and Other Health Care Providers
283015	Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	Form and Instruction	New	CMS-10826.Recruitment Guide – Teaching Hospital Representatives
282986	Oral Health Illustration Survey (CMS-10864)	Other-Illustrations	New
282986	Oral Health Illustration Survey (CMS-10864)	Form and Instruction	New	Oral Health Survey Plan
282982	Patient Subject Matter Expert (PSME) Satisfaction Survey (CMS-10859)	Form and Instruction	New	PSME Satisfaction Survey
282981	J.9 Network Satisfaction Survey (CMS-10841)	Form and Instruction	New	J.9 Customer Satisfaction Survey
282972	Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	Form and Instruction	New	CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007
282972	Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	Form and Instruction	New	CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803
282968	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) - Observed Testing (CMS-10754)	Form and Instruction	New	Observed Testing Protocol
282968	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) - Observed Testing (CMS-10754)	Instruction	New
282968	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) - Observed Testing (CMS-10754)	Form and Instruction	New	GADCS Feedback Application
282965	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Instruction	New
282965	User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	Form and Instruction	New	GADCS Draft Feedback Clean
282890	Account Manager Satisfaction Survey (CMS-10748)	Form	New	Account Manager Satisfaction Survey
282888	Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	Form and Instruction	New	CMS-10729 Beneficiary Care Management Program Beneficiary Satisfaction Survey
282887	12th SOW Patient Activation Assessment (CMS-10723)	Form and Instruction	New	CMS-10723.Patient Activation Assessment
282886	MACBIS Software Application Electronic Surveys for Users (CMS-10719)	Form	New	MACBIS Software Application Electronic Survey
282885	End Stage Renal Disease Grievant Satisfaction Survey	Form and Instruction	New	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey
282884	Medicare.gov Sitewide Qualtrics (CMS-10676)	Form and Instruction	New	CMS-10676.Medicare.gov Sitewide Qualtrics Survey
282882	Medicare.gov Medicare Plan Finder Survey	Form and Instruction	New	CMS-10415. Fast Track Medicaregov - Medicare Plan Finder Survey
282881	CMS.gov User Satisfaction Survey	Form and Instruction	New	CMS-10415.Fast Track CMSgov Survey (2)
282880	Beneficiary Contact Center Customer Satisfaction Survey	Form and Instruction	New	IVR Phone Script

ICR Details

OMB Control No: 0938-1185	ICR Reference No: 202610-0938-001
Status: Received in OIRA	Previous ICR Reference No: 202211-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: OC
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/14/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,000,000	0
Time Burden (Hours)	60,000	0
Cost Burden (Dollars)	0	0

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Abstract: This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the agency's programs. This feedback will provide insights into customer or stakeholder perceptions, experiences and expectations, provide an early warning of issues with service, or focus attention on areas where communication, training or changes in operations might improve delivery of products or services. These collections will allow for ongoing, collaborative and actionable communications between the Agency and its customers and stakeholders. It will also allow feedback to contribute directly to the improvement of program management.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 31256	06/10/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 61453	10/07/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 27

table that charts list of burden

IC Title	Form No.	Form Name
Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826)	CMS-10826, CMS-10826, CMS-10826, CMS-10826	CMS-10826.Recruitment Guide – Teaching Hospital Representatives ,   CMS-10826.Recruitment Guide for Physicians and Other Health Care Providers ,   CMS-10826.Health Care Providers (Primary Care and Specialist) ,   CMS-10826.Users-Checked Data (Physicians and Teaching Hospitals) (revised)
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754)	CMS-10754	GADCS Draft Feedback Clean
12th SOW Patient Activation Assessment (CMS-10723)	CMS-10723	CMS-10723.Patient Activation Assessment
Account Manager Satisfaction Survey (CMS-10748)	CMS-10748	Account Manager Satisfaction Survey
Account Manager Satisfaction Survey (CMS-10748)	CMS-10748, CMS-10748, CMS-10748	PACE Organization Survey ,   Medicare Advantage Organization Survey ,   ACA Issuers Survey
Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729)	CMS-10729	CMS-10729 Beneficiary Care Management Program Beneficiary Satisfaction Survey
Beneficiary Contact Center Customer Satisfaction Survey	CMS-10415	IVR Phone Script
Blue Button 2.0 Developer Experience Customer Satisfaction Survey (CMS-10924)	CMS-10924	DevEx Survey (2026)
CCW VRDC Stakeholder Engagement Plan (CMS-10880)	CMS-10880, CMS-10880	VRDC Survey Questions ,   Focus Group Session Moderator Guide Script
CMS.gov User Satisfaction Survey	CMS-10415	CMS-10415.Fast Track CMSgov Survey (2)
Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820)	CMS-10820, CMS-10820	CMS-10820. CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803 ,   CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007
Data Collection for Education and Outreach for the Yello System (CMS-10872)	CMS-10872	CMS Applicant Information Collection Form
Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form (CMS-10892)	CMS-10892	Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form
End Stage Renal Disease Grievant Satisfaction Survey	CMS-10415	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey
Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827)	CMS-10827, CMS-10827, CMS-10827, CMS-10827	2 - CMS-10827. Recruitment Guide - Open Payments Consumer (revised) ,   3 - CMS-10827. Consent Form - Open Payments Consumer (revised) ,   CMS-10827. Mod Guide A - Open Payments Consumer (revised) ,   5 - CMS-10827. Mod Guide B - Open Payments Consumer (revised)
J.9 Network Satisfaction Survey (CMS-10841)	CMS-10841	J.9 Customer Satisfaction Survey
MACBIS Software Application Electronic Surveys for Users (CMS-10719)	CMS-10719	MACBIS Software Application Electronic Survey
MACBIS Software Application Electronic Surveys for Users -Webinar Survey Polling Questions (CMS-10719)	CMS-10719	MACBIS Software Application Electronic Survey
Medicare.gov Medicare Plan Finder Survey	CMS-10415	CMS-10415. Fast Track Medicaregov - Medicare Plan Finder Survey
Medicare.gov Sitewide Qualtrics (CMS-10676)	CMS-10676	CMS-10676.Medicare.gov Sitewide Qualtrics Survey
Oral Health Illustration Survey (CMS-10864)	CMS-10864	Oral Health Survey Plan
Patient Subject Matter Expert (PSME) Satisfaction Survey (CMS-10859)	CMS-10859	PSME Satisfaction Survey
Post Conference Event Feedback Request (CMS-10879)	CMS-10879	Post-Conference Event Feedback Request
Post-Acute Care Training Project (10873)	CMS-10873	Post-Event/Post-Training Survey
Quality Improvement of IPPTA Processes and Procedures (CMS-10894)	CMS-10894, CMS-10894, CMS-10894, CMS-10894, CMS-10894	Preparation: SBEs for IPPTA ,   Data documentation Submission and Sampling ,   Conduct Reviews ,   Observation and Collaboration ,   SBE Closeout
Surveying our Customers – Post-activity Evaluation (CMS-10732)	CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732, CMS-10732	Customer and Stakeholder Feedback: Providers/Suppliers ,   Customer and Stakeholder Feedback: Medicare Beneficiary ,   Customer and Stakeholder Feedback: Marketplace Consumer ,   Customer and Stakeholder Feedback: SHIP or Other Assister or Partner ,   Customer and Stakeholder Feedback: All (Webinar) ,   Customer and Stakeholder Feedback: Medicare Beneficiary (Spanish) ,   Customer and Stakeholder Feedback: SHIP or Other Assister or Partner (Spanish) ,   Customer and Stakeholder Feedback: Providers/Suppliers (Spanish) ,   Customer and Stakeholder Feedback: Marketplace Consumer (Spanish)
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) - Observed Testing (CMS-10754)	CMS-10754, CMS-10754	GADCS Feedback Application ,   Observed Testing Protocol

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,000,000	0	0	0	0	1,000,000
Annual Time Burden (Hours)	60,000	0	0	0	0	60,000
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $250,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/14/2026

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