View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	iQIES Post-Launch Sentiment Survey (CMS-10926)	Agency IC Tracking Number:	CCSQ

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-10926	Qualtrics Survey - QEM	Qualtrics Survey _ Qualtrics Experience Management.pdf		Yes	Yes	Fillable Fileable
Instruction			Qualtrics Survey instructions_ QEM .pdf		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: 200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	200	0	200	0	0	0
Annual IC Time Burden (Hours)	7	0	7	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	CMS-10926 ICRTEM_1.final.docx	05/22/2025

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