Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
(CMS-10879) Post Conference Event Feedback Request New 2000 83 0 Form and Instruction CMS-10879 Post-Conference Event Feedback Request
12th SOW Patient Activation Assessment (CMS-10723) New 100000 3333 0 Form and Instruction CMS-10723 CMS-10723.Patient Activation Assessment
2023 IPRO ESRD Collaborator Satisfaction Survey (CMS-10750) New 1453 245 0 Form and Instruction CMS-10750 DRAFT IPRO ESRD Network 1 Collaborator Survey (2023)
Form and Instruction CMS-10750 DRAFT IPRO ESRD Network 2 Collaborator Survey (2023)
Form and Instruction CMS-10750 DRAFT IPRO ESRD Network 6 Collaborator Survey (2023)
Form and Instruction CMS-10750 DRAFT IPRO ESRD Network 9 Collaborator Survey (2023)
Account Manager Satisfaction Survey (CMS-10748) New 425 71 0 Form CMS-10748 PACE Organization Survey
Form CMS-10748 Medicare Advantage Organization Survey
Form CMS-10748 ACA Issuers Survey
Other-Emails to Plan Sponsors
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 Survey
Beneficiary Care Management Program, Beneficiary Experience Survey (CMS-10729) New 600 50 0 Form and Instruction CMS-10729 Beneficiary Care Management Program Beneficiary Satisfaction Survey_041420
Beneficiary Contact Center Customer Satisfaction Survey New 145000 5776 0 Form and Instruction CMS-10415 IVR Phone Script
Blue Button 2.0 Developer Experience Customer Satisfaction Survey. (CMS-10924) New 220 77 0 Form and Instruction CMS-10924 DevEx Survey
CCW VRDC Stakeholder Engagement Plan (CMS-10880) New 1620 615 0 Form and Instruction CMS-10880 VRDC Survey Questions
Form and Instruction CMS-10880 Focus Group Session Moderator Guide Script
CMS-10811. Medicare Parts C and D Improper Payment Measure (IPM) (REVISON) New 900 45 0 Form and Instruction CMS-10811 CMS-10811.Appendix A_Part C IPM Survey Questions
Form and Instruction CMS-10811 CMS-10811.Appendix B_Part D IPM Survey Questions
CMS.gov User Satisfaction Survey New 10000 333 0 Form and Instruction CMS-10415 CMS.gov User Satisfaction Survey
COVID-19 Campaign Survey on Fee-for-Service CMS.gov (CMS-10766) New 4872 81 0 Form and Instruction CMS-10766 CMS-10766.Instrument for COVID-19 Campaign Page Feedback Survey
Clinician Focus Groups on Telehealth and Social Determinants of Health (CMS-10820) New 148 73 0 Form and Instruction CMS-10820 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.docx
Data Collection for Education and Outreach for the Yello System (CMS-10872) New 284000 9488 0 Form and Instruction CMS-10872 CMS Applicant Information Collection Form
Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form (CMS-10892) New 600 50 0 Form and Instruction CMS-10892 Emergency Medical Treatment and Labor Act (EMTALA) Complaint Form
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
Foundational Generative In-Depth Interviews for Medicare Enrollees Seeking Their Medicare Claims Data (CMS-10903) New 1220 222 0 Form and Instruction CMS-10903 CMS-10903. Attachment A - Generative In-Depth Interview Guide
Form and Instruction CMS-10903.Attachment B CMS-10903.Attachment B - Medicare Enrollee Eligibility Screener
Form and Instruction CMS-10903 CMS-10903. Attachment C - Consent form
Health Care Consumer Feedback on Open Payments National Transparency Program (Open Payments) (CMS-10827) New 360 200 0 Form and Instruction CMS-10827 2 - CMS-10827. Recruitment Guide - Open Payments Consumer (revised)
Form and Instruction CMS-10826 3 - CMS-10827. Consent Form - Open Payments Consumer (revised)
Form and Instruction CMS-10826 4 - CMS-10827. Mod Guide A - Open Payments Consumer (revised)
Form and Instruction CMS-10826 5 - CMS-10827. Mod Guide B - Open Payments Consumer (revised)
Health Care Provider Feedback on Open Payments National Transparency Program (Open Payments) - (CMS-10826) New 138 44 0 Form and Instruction CMS-10826 CMS-10826.Recruitment Guide – Teaching Hospital Representatives (revised).docx
Form and Instruction CMS-10826 CMS-10826.Recruitment Guide for Physicians and Other Health Care Providers
Form and Instruction CMS-10826 CMS-10826.Health Care Providers (Primary Care and Specialist)
Form and Instruction CMS-10826 CMS-10826.Users-Checked Data (Physicians and Teaching Hospitals) (revised)
Health Equity Conference Satisfaction Survey and Interviews (CMS-10890) New 2500 208 0 Form and Instruction CMS-10890 2024 CMS Health Equity Conference Feedback Survey
IPRO Collaborator Satisfaction Survey-Request for Approval-Nursing Homes (CMS-10776) New 964 161 0 Form and Instruction CMS-10776 Collaborator Survey Nursing Home
IPRO Community of Care Coalitions Collaborator Survey (2023)(CMS-10771) New 9 2 0 Form and Instruction CMS-10771 IPRO Partnership for Community Health Coalition Initiative Collaborator Survey (2023)
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 (2023) (CMS-10770) New 4 1 0 Form and Instruction CMS-10770 DRAFT IPRO Drug Safety Program Collaborator Survey (2023)
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 Collaborator Survey
Form and Instruction CMS-10750 NW 2 Collaborator Survey
Form and Instruction CMS-10750 NW 6 Collaborator Survey
Form and Instruction CMS-10750 NW 9 Collaborator Survey
IPRO Nursing Home Collaborator Satisfaction Survey (2023) (CMS-10776) New 200 33 0 Form and Instruction CMS-10776 IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2023)
J.9 Network Satisfaction Survey (CMS-10841) New 7794 257 0 Form and Instruction CMS-10841 J.9 Customer Satisfaction 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 - Webinar Survey Polling Questions (CMS-10719) New 2081 173 0 Form CMS-10719 MACBIS Software Application Electronic Survey
Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763) New 3000 150 0 Form and Instruction CMS-10763 CMS-10763.Medical Review Survey - English final
Form and Instruction CMS-10763 CMS-10763.Medical Review Survey - Spanish final
Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback (CMS-10721) New 45000 750 0 Form and Instruction CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey
Form and Instruction CMS-10721 CMS-10721.Final Persistent Portal Feedback Survey (Spanish)
Form and Instruction CMS-10721 CMS-10721.Final Persistent Website Feedback Survey
Form and Instruction CMS-10721 CMS-10721.Final Persistent Website Feedback Survey (Spanish)
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 Question List.docx
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 Final Overall Website Feedback Survey
Form and Instruction CMS-10720 Final Overall Portal Feedback Survey.docx
Form and Instruction CMS-10720 CMS-10720.Final Overall Website Feedback Survey (Spanish)
Form and Instruction CMS-10720 CMS-10720.Final Overall Portal Feedback Survey (Spanish)
Medicare Administrative Contractor (MAC) Provider Customer Experience – Mobile Application (CMS-10761) New 500 25 0 Form and Instruction CMS-10761 Final Overall Mobile Feedback Survey-final
Form and Instruction CMS-10761 Final Overall Mobil Application Feedback Survey (Spanish)-final (1)
Medicare Administrative Contractor (MAC) Provider Experience Persistent Feedback – Mobile Application (CMS-10762) New 500 8 0 Form and Instruction CMS-10762 Final Persistent Mobile Feedback Survey
Form and Instruction CMS-10762 CMS-10762.Final Persistent Mobil Application 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 Fee-for-Service Provider Communications Preferences Survey (CMS-10876) New 2550 638 0 Form and Instruction CMS-10876 Provider Communication Needs Survey (final).docx
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 Survey (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 Medicare.gov - Medicare Plan Finder Survey
Oral Health Illustration Survey (CMS-10864) New 100 17 0 Other-Illustrations
Form and Instruction CMS-10864 Oral Health Survey Plan
Overall Flu Campaign Feedback Survey (CMS-10760) New 4872 81 0 Form and Instruction CMS-10760 Overall Flue Campaign Feedback Survey
Patient Subject Matter Expert (PSME) Satisfaction Survey (CMS-10859) New 198698 6557 0 Form and Instruction CMS-10859 PSME Satisfaction Survey
Post-Acute Care Training Project (10873) New 3000 100 0 Form and Instruction CMS-10873 Post-Event/Post-Training Survey
Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Cognitive Testing New 50 50 0 Form CMS-10889 QHP Cognitive Testing Consumer Consent Form
Form CMS-10889 Recruitment Screener
Form CMS-10889 Testing Protocol
Form CMS-10889 QHP Cognitive Testing Survey
Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Focus Groups with Consumers and QHP Issuers (CMS-10869) New 40 9 0 Form and Instruction CMS-10869 Attachment A - Recruitment Screeners for Consumer and Issuer Focus Groups
Form and Instruction CMS-10869 Attachment B: Consent Forms for Consumers and Issuers
Form and Instruction CMS-10869 Attachment C: CMS QHP Enrollee Survey Consumer Focus Group Protocol
Form and Instruction CMS-10869 Attachment D: CMS QHP Enrollee Survey QHP Issuer Focus Group Protocol
Quality Improvement of IPPTA Processes and Procedures New 19 228 0 Form and Instruction CMS-10894 Preparation: SMEs for IPPTA
Form and Instruction CMS-10894 Data documentation Submission and Sampling
Form and Instruction CMS-10894 Conduct Reviews
Form and Instruction CMS-10894 Observation and Collaboration
Form and Instruction CMS-10894 SBE Closeout
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 CMS-10590.QualityNet_User_Survey
Replacing Durable Medical Equipment and 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
Survey Refinement for the Qualified Health Plan Enrollee Experience Survey (CMS-10726) New 40 90 0 Form and Instruction CMS-10726 Attachment A-Consumer and Issuer Recruitment Language (FG and CT)
Form and Instruction CMS-10726 Attachment B-Consent Forms
Form and Instruction CMS10726 Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020
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)
Form CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary (Spanish)
Form CMS-10732 Customer and Stakeholder Feedback: SHIP or Other Assister or Partner (Spanish)
Form CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers (Spanish)
Form CMS-10732 Customer and Stakeholder Feedback: Marketplace Consumer (Spanish)
Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682) New 50 13 0 Form CMS-10682 CMS_OCS_TestingQuestions_SitemapTesting.docx
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: 1094738 46197 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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