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OMB Control No: 0938-1177	ICR Reference No: 201203-0938-008
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Beneficiary and Family-Centered Satisfaction Survey
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 03/23/2012
	Date Received in OIRA: 03/13/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

Abstract: The data collection methodology used for the Beneficiary Satisfaction flows from the proposed sampling approach. While it was feasible to conduct the 9th SOW via telephone data collection only, with a quarterly sample size for the 10th SOW estimated to be 2,664, it does not seem efficient to maintain a telephone only data collection approach. Based on recent literature on survey methodology and response rates by mode, we recommend using a data collection that is primarily mail. A mail-based methodology will achieve the goals of being efficient, effective, and minimally burdensome for beneficiary respondents. As previously described, we anticipate that a mail-based methodology could yield a response rate of approximately 60 percent. In order to achieve this response rate, we would recommend a 3 staged approach to data collection: 1) Mailout of a covering letter, the paper survey questionnaire, and a postage-paid return envelope. 2) Mailout of a post card that thanks respondents and reminds the non-respondents to please return their survey. 3) Mailout of a follow-up covering letter, the paper survey questionnaire, and a postage-paid return envelope. Through the pilot test, we will determine the response rate that can be achieved using this approach. If it is deemed necessary, additional mailout reminders can be added to the protocol, or a telephone non-response step can be added to the protocol.

Authorizing Statute(s): US Code: 42 USC 1320C-3 Name of Law: Functions of Peer Review Organizations

Citations for New Statutory Requirements: US Code: 42 USC 1320-c Name of Law: Functions of Peer Review Organizations

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 34076	06/10/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 14806	03/13/2012
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Beneficiary and Family-Centered Satisfaction Survey	CMS-10393, CMS-10393	,

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: While there have been program changes, there is not change to the burden estimate. Subsequent to the publication of the 60-day Federal Register notice (June 10, 2011; 76 FR 34076), the survey instrument has been separated into two surveys. Prior to this action, there was one survey proposed for the Quality of Care and Appeals review types. Once approved by OMB, there will be two survey instruments that will request similar information: one for Quality of Care and one for Appeals.

Annual Cost to Federal Government: $2,024,620

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

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