View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	CMS-10766. COVID-19 Campaign Survey on Fee-for-Service CMS.gov	Agency IC Tracking Number:	CM

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 and Instruction	CMS-10766	COVID-19 Campaign Survey on Fee-for-Service CMS.gov	CMS-10766.Instrument for COVID-19 Campaign Page Feedback Survey.docx		Yes	Yes	Fillable Fileable

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: 4,872	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 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	4,872	0	4,872	0	0	0
Annual IC Time Burden (Hours)	81	0	81	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10766.COVID_19 Campaign Survey Fast Track	CMS-10766.COVID_19 Campaign Survey Fast Track.docx	11/16/2020

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