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Potential Refinements to the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey): Cognitive Testing OC
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10889 QHP Cognitive Testing Consumer Consent Form QHP Cognitive Testing Consumer Consent Form_d.docx No   Paper Only
Form CMS-10889 Recruitment Screener QHP Cognitive Testing Recruitment Screener_d.docx No   Paper Only
Form CMS-10889 Testing Protocol QHP Cognitive Testing Survey Mockup_final_revised for OMB_clean.docx No   Paper Only
Form CMS-10889 QHP Cognitive Testing Survey QHP Cognitive Testing Protocol_final_updated with SOGI alternatives (16 Feb 24)_clean.docx No   Paper Only

Health Health Care Services

 

50 0
   
Individuals or Households
 
   0 %

  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 50 0 50 0 0 0
Annual IC Time Burden (Hours) 50 0 50 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Generic Clearance Document QHP Cognitive Testing PRA-CSForm_final.docx 01/29/2024
CMS-10889 - Generic Clearance Template CMS-10889 - Generic Clearance Template_final.docx 01/30/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.