View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Medicare Beneficiary and Family-Centered Satisfaction Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10393				No	No	Paper Only
Form	CMS-10393				No	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 68,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	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	68,000	68,000	0	0	0	0
Annual IC Time Burden (Hours)	17,000	17,000	0	0	0	0
Annual IC Cost Burden (Dollars)	85,000	85,000	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk		03/12/2012

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

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