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

OMB 0938-1185

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.

The latest form for Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415) expires 2022-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10820 Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820) Form and Instruction
Form CMS-10828 Replacing Durable Medical Equipment and Prescription Drugs after a Disaster Addressing the Needs of Medicare Beneficiaries Post-training Feedback Survey (CMS-10828) Form and Instruction
Form CMS-10815 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815) Form
Form CMS-10814 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814) Form
Form CMS-10813 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813) Form
Form CMS-10812 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812) Form
Form CMS-10811 Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811) Form and Instruction
Form CMS-10754 User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754) Form and Instruction
Form CMS-10771 IPRO Community of Care Coalitions Collaborator Survey (CMS-10771) Form and Instruction
Form CMS-10770 IPRO Drug Safety Program Collaborator Survey (CMS-10770) Form and Instruction
Form CMS-10754 User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754) Form and Instruction
Form CMS-10776 IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776) Form and Instruction
Form CMS-10748 Account Manager Satisfaction Survey (CMS-10748) Form
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users - Webinar Survey Polling Questions (CMS-10719) Form
Form CMS-10766 COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766) Form and Instruction
Form CMS-10763 Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763) Form and Instruction
Form CMS-10762 Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762) Form and Instruction
Form CMS-10761 Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761) Form and Instruction
Form CMS-10760 Overall Flu Campaign Feedback Survey (CMS-10760) Form and Instruction
Form CMS-10750 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750) Form and Instruction
Form CMS-10748 Account Manager Satisfaction Survey (CMS-10748) Form
Form CMS-10746 Medicare Casework Customer Satisfaction Survey (CMS-10746) Form and Instruction
Form CMS-10732 Surveying our Customers – Post-activity Evaluation (CMS-10732) Form
Form CMS-10729 Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729) Form and Instruction
Form CMS-10723 12th SOW Patient Activation Assessment (CMS-10723) Form and Instruction
Form CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726) Form and Instruction
Form CMS-10721 Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721) Form and Instruction
Form CMS-10720 Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720) Form and Instruction
Form CMS-10719 MACBIS Software Application Electronic Surveys for Users (CMS-10719) Form
Form CMS-10415. GenIC#5 End Stage Renal Disease Grievant Satisfaction Survey Form and Instruction
Form CMS-10682 Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682) Form
Form CMS-10676 Medicare.gov Sitewide Qualtrics Survey (CMS-10676) Form and Instruction
Form CMS-10415 Medicaregov Medicare Plan Finder Survey Form and Instruction
Form CMS-10415 CMS.gov User Satisfaction Survey Form and Instruction
Form CMS-10590 QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590) Form and Instruction
Form CMS-10588 Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588) Form and Instruction
Form CMS-10415 Beneficiary Contact Center Customer Satisfaction Survey Form and Instruction
CMS-10415_Supporting Statement A - 2022.docx Supporting Statement A
CMS-10415_Supporting_Statement_Part_B.docx Supporting Statement B
Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820) Form and Instruction
Replacing Durable Medical Equipment and Prescription Drugs after a Disaster Addressing the Needs of Medicare Beneficiaries Post-training Feedback Survey (CMS-10828) Form and Instruction
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815) Form
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814) Form
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813) Form
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812) Form
Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811) Form and Instruction
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754) Form and Instruction
IPRO Community of Care Coalitions Collaborator Survey (CMS-10771) Form and Instruction
IPRO Drug Safety Program Collaborator Survey (CMS-10770) Form and Instruction
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754) Form and Instruction
IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776) Form and Instruction
Account Manager Satisfaction Survey (CMS-10748) Form
MACBIS Software Application Electronic Surveys for Users - Webinar Survey Polling Questions (CMS-10719) Form
COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766) Form and Instruction
Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763) Form and Instruction
Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762) Form and Instruction
Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761) Form and Instruction
Overall Flu Campaign Feedback Survey (CMS-10760) Form and Instruction
IPRO ESRD Collaborator Satisfaction Survey (CMS-10750) Form and Instruction
Account Manager Satisfaction Survey (CMS-10748) Form
Medicare Casework Customer Satisfaction Survey (CMS-10746) Form and Instruction
Surveying our Customers – Post-activity Evaluation (CMS-10732) Form
Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729) Form and Instruction
12th SOW Patient Activation Assessment (CMS-10723) Form and Instruction
Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726) Form and Instruction
Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721) Form and Instruction
Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720) Form and Instruction
MACBIS Software Application Electronic Surveys for Users (CMS-10719) Form
End Stage Renal Disease Grievant Satisfaction Survey Form and Instruction
Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682) Form
Medicare.gov Sitewide Qualtrics Survey (CMS-10676) Form and Instruction
Medicaregov Medicare Plan Finder Survey Form and Instruction
CMS.gov User Satisfaction Survey Form and Instruction
QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590) Form and Instruction
Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588) Form and Instruction
Beneficiary Contact Center Customer Satisfaction Survey Form and Instruction

All Historical Document Collections

202211-0938-011 Approved with change	Revision of a currently approved collection	2022-11-29
201904-0938-017 Approved with change	Revision of a currently approved collection	2019-04-30
201703-0938-009 Withdrawn and continue	No material or nonsubstantive change to a currently approved collection	2017-03-09
201611-0938-004 Approved with change	No material or nonsubstantive change to a currently approved collection	2016-11-10
201605-0938-002 Approved with change	No material or nonsubstantive change to a currently approved collection	2016-05-02
201512-0938-013 Approved with change	Revision of a currently approved collection	2015-12-30
201508-0938-014 Withdrawn and continue	No material or nonsubstantive change to a currently approved collection	2015-08-28
201506-0938-013 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-06-26
201412-0938-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-12-17
201210-0938-003 Approved without change	New collection (Request for a new OMB Control Number)	2012-10-01
201206-0938-002 Improperly submitted	New collection (Request for a new OMB Control Number)	2012-06-08

OMB Details

Beneficiary Contact Center Customer Satisfaction Survey

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10415

IVR Phone Script

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.