Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
(CMS-10723) 12SOW Patient Activiation Assessment New 100000 3333 0 Form and Instruction CMS-10723 Patient Activation Survey
(CMS-10776) IPRO 2020 Collaborator Satisfaction Survey-Request for Approval-Nursing Homes New 964 161 0 Form and Instruction CMS-10776 Collaoborator Survey Nursing Home
Account Manager Satisfaction Survey (CMS-10748) New 300 50 0 Form CMS-10748 Account Manager Satisfaction Survey
Account Manager Satisfaction Survey (CMS-10748) New 300 5 0 Form CMS-10748 Account Manager Satisfaction Survey
Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729) New 600 50 0 Form and Instruction CMS-10729 Beneficiary Satisfaction Survey
Beneficiary Contact Center Customer Satisfaction Survey New 145000 5776 0 Form and Instruction CMS-10415 IVR Phone Script
CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey New 40 90 0 Form and Instruction CMS-10726 Consumer and Issuer Recruitment Language
Form and Instruction CMS-10726 Consent Forms
Form and Instruction CMS-10726 Descripton of Focus Groups and Cognitive Testing Protocols
CMS-10760.Overall Flu Campaign Feedback Survey New 4872 81 0 Form and Instruction CMS-10760 Overall Flu Campaign Feedback Survey
CMS-10761. Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application New 500 25 0 Form and Instruction CMS-10761 CMS-10761.Final Overall Mobile Feedback Survey (English)
Form and Instruction CMS-10761 CMS-10761.Final Overall Mobile Application Feedback Survey (Spanish)
CMS-10762. Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application New 500 8 0 Form and Instruction CMS-10762 : CMS-10762.Final Persistent Mobile Application Feedback Survey (Spanish)
Form and Instruction CMS-10762 CMS-10762.Final Persistent Mobile Feedback Survey (English)
CMS-10763.Medicare Administrative Contactors Customer Experience – Medical Review New 3000 150 0 Form and Instruction CMS-10763 CMS-10763.Medical Review Survey (Spanish).docx
Form and Instruction CMS-10763 CMS-10763.Medical Review Survey (English).docx
CMS-10766. COVID-19 Campaign Survey on Fee-for-Service CMS.gov New 4872 81 0 Form and Instruction CMS-10766 COVID-19 Campaign Survey on Fee-for-Service CMS.gov
CMS.gov User Satisfaction Survey New 10000 333 0 Form and Instruction CMS-10415 CMS.gov User Satisfaction Survey
Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820) New 148 73 0 Form and Instruction CMS-10820 CMS OBRHI_Clinician Focus Groups_Moderators Guide_Rev 20220803
Form and Instruction CMS-10820 CMS OBRHI_Clinician Focus Groups_Eligibility Screener_Rev 20221007
Electronic Medical Documentation Interoperability (EMDI) Workgroup Survey (CMS-10679) New 120 40 0 Form and Instruction CMS-10679 EMDI_Workgroup_Participation_Survey
End Stage Renal Disease Grievant Satisfaction Survey New 384 77 0 Form and Instruction CMS-10415.GenIC #5 End Stage Renal Disease (ESRD) Grievant Satisfaction Survey
End Stage Renal Disease Quality Reporting System (EQRS) Customer Satisfaction and Task Prioritization Survey for the EQRS Release 1.0 Project (CMS-10626) New 200 50 0 Form and Instruction CMS-10626 CrownWeb Facility User Survey
Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs New 100000 417 0 Form and Instruction CMS-10415 Evaluation of Stakeholder Training
IPRO Community of Care Coalitions Collaborator Survey (CMS-10771) New 50 8 0 Form and Instruction CMS-10771 IPRO Collaborator - Community of Care Coalitions Survey
IPRO Drug Safety Program Collaborator Survey (CMS-10770) New 16 3 0 Form and Instruction CMS-10770 IPRO Collaborator Drug Safety Survey
IPRO ESRD Collaborator Satisfaction Survey (CMS-10750) New 560 93 0 Form and Instruction CMS-10750 NW 1 Colaborator Survey
Form and Instruction CMS-10750 NW 2 Colaborator Survey
Form and Instruction CMS-10750 NW 6 Colaborator Survey
Form and Instruction CMS-10750 NW 0 Colaborator Survey
MACBIS Software Application Electronic Surveys for Users (CMS-10719) New 2081 173 0 Form CMS-10719 MACBIS Software Application Electronic Surveys for Users
MACBIS Software Application Electronic Surveys for Users (CMS-10719) New 2081 173 0 Form CMS-10719 MACBIS Software Application Electronic Survey
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812) New 5000 250 0 Form CMS-10812 CMS-10812. Audit and Reimbursement - Website
Form CMS-10812 CMS-10812. Audit and Reimbursement - Letter
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Palmetto Web Chat Library of Questions (CMS-10813) New 1560 52 0 Form CMS-10813 Web Chat Survey
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Telephone Library of Questions (CMS-10815) New 60000 2000 0 Form CMS-10815 CMS-10815. Call Center Questions
Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Provider Contact Center - Written Correspondence Survey (CMS-10814) New 10000 500 0 Form CMS-10814 CMS-10814. Written Correspondence Instrument
Medicare Administrative Contractor (MAC) Provider Customer Experience (CMS-10720) New 35000 1750 0 Form and Instruction CMS-10720 Overall Website Feedback Survey.docx
Form and Instruction CMS-10720 Final Overall Portal Feedback Survey (Spanish)
Form and Instruction CMS-10720 Final Overall Website Feedback Survey (Spanish).docx
Form and Instruction CMS-10720 Final Overall Portal Feedback Survey.docx
Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721) New 45000 750 0 Form and Instruction CMS-10721 Final Persistent Website Feedback Survey
Form and Instruction CMS-10721 Final Persistent Website Feedback Survey (Spanish)
Form and Instruction CMS-10721 Final Persistent Portal Feedback Survey
Form and Instruction CMS-10721 Final Persistent Portal Feedback Survey (Spanish)
Medicare Casework Customer Satisfaction Survey (CMS-10746) New 5000 167 0 Form and Instruction CMS-10746 Script: Medicare Casework Customer Satisfaction Survey
Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811) New 900 45 0 Form and Instruction CMS-10811 CMS-10811. Appendix A_Part C Survey Questions FINAL
Form and Instruction CMS-10811 CMS-10811. Appendix B_Part D Survey Questions FINAL
Medicare.gov Sitewide Qualtrics (CMS-10676) New 100000 8333 0 Form and Instruction CMS-10676 Medicare.gov Sitewide Qualtrics Survey
Medicaregov - Medicare Plan Finder Survey New 25000 833 0 Form and Instruction CMS-10415 Medicaregov - Medicare Plan Finder Survey
QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS- 10590) New 500 83 0 Form and Instruction CMS-10590 QualityNetPortal_UserSurvey
Replacing Durable Medical Equipment & Prescription Drugs after a Disaster: Addressing the Needs of Medicare Beneficiaries" post-training feedback survey (CMS-10828) New 60 10 0 Form and Instruction CMS-10828 Post-webinar Feedback Survey
Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys (CMS-10534) New 90 106 0 Form and Instruction CMS-10534 Cognitive Interview Guide, Screener and Consent Forms
Surveying our Customers – Post-activity Evaluation (CMS-10732) New 22320 1116 0 Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner
Form CMS-10732 Customer and Stakeholder Feedback: All (Webinar)
Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682) New 50 13 0 Form CMS-10682 CMS-10682.CMS_OCS_TestingQuestions_SitemapTesting
Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588) New 40 32 0 Form and Instruction CMS-10588 Usability Test Script
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754) New 80 160 0 Form and Instruction CMS-10754 GADCS Feedback Application
Instruction
User Acceptance Testing for the Medicare Ground Ambulance Data Collection System (GADCS) (CMS-10754) New 60 120 0 Form and Instruction CMS-10754 GADCS Feedback Application
Instruction
Form and Instruction CMS-10754 Observed Testing Protocol
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 687248 27570 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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