View Information Collection (IC)

View Information Collection (IC)

Adult Qualified Health Plan Enrollee Experience Survey
 
No Modified
 
Voluntary
 
45 CFR 156.200(b)(5) 45 CFR 155.200(d)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10488 Vendor Form ESS Survey Vendor Participation Form.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10488 QHP Enrollee Survey (Beta Test) - Chinese Chinese Adult QHP Enrollee Survey for Beta Test_9-9-14_Clean.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10488 QHP Enrollee Survey (Beta Test) - English English Adult QHP Enrollee Survey for Beta Test_9-9-14_Clean.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10488 QHP Enrollee Survey (Beta Test) - Spanish Spanish Adult QHP Enrollee Survey for Beta Test_9-9-14_Clean.docx Yes Yes Fillable Fileable

Health Health Care Services

 

180,010 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 180,010 0 -424,230 0 0 604,240
Annual IC Time Burden (Hours) 57,610 0 -214,320 0 0 271,930
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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