View Information Collection Request (ICR) Package
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View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View Generic ICR - OIRA Conclusion
OMB Control No:
0938-1185
ICR Reference No:
201412-0938-006
Status:
Historical Active
Previous ICR Reference No:
201210-0938-003
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
12/18/2014
Retrieve Notice of Action (NOA)
Date Received in OIRA:
12/17/2014
Terms of Clearance:
Previous terms continue: OMB approves this collection for a period of three years. To request approval of information collections under this generic approval, the agency must do the following: 1) Unless an agency is using multiple modes of collection (e.g., paper forms and electronic submissions), provide a Generic Clearance Submission Template for each Instrument; 2) If the agency is using multiple modes of collection (e.g., paper forms and electronic submissions), the same Generic Clearance Submission Template may be used for both instruments; 3) each Generic Clearance Submission Template must be uploaded as a Supplementary document using a naming convention that allows the public to identify the associated instrument; 4) submit no more than five Generic Submission Templates with each request.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2015
12/31/2015
12/31/2015
Responses
1,000,000
0
1,000,000
Time Burden (Hours)
25,000
0
25,000
Cost Burden (Dollars)
0
0
0
Abstract:
This collection of information is necessary to enable the Agency to garner customer and stakeholder feedback in an efficient, timely manner, in accordance with our commitment to improving service delivery. The information collected from our customers and stakeholders will help ensure that users have an effective, efficient, and satisfying experience with the agency's programs. This feedback will provide insights into customer or stakeholder perceptions, experiences and expectations, provide an early warning of issues with service, or focus attention on areas where communication, training or changes in operations might improve delivery of products or services. These collections will allow for ongoing, collaborative and actionable communications between the Agency and its customers and stakeholders. It will also allow feedback to contribute directly to the improvement of program management.
Authorizing Statute(s):
EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
Citations for New Statutory Requirements:
EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
EO: EO 13571 Name/Subject of EO: Streamlining Service Delivery and Improving Customer Service
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:
75 FR 80542
12/22/2010
30-day Notice:
Federal Register Citation:
Citation Date:
77 FR 31616
05/29/2012
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
13
IC Title
Form No.
Form Name
(CMS-10546) Survey for Long-Term (LT) and Post-Acute Care (PAC) Electronic Health Records (EHR) and Health Information Exchange (HIE) Adoption
CMS-10546
Utilization of Health Information Technology in Post-Acute Care Settings
(CMS-10560) Focus Groups to Inform the Development of a Marketplace Dental Survey
CMS-10560
Focus Group Eligibility Screener, Consent form and Protocol
Beneficiary Contact Center Customer Satisfaction Survey
CMS-10415
IVR Phone Script for Survey
Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557)
CMS-10557
Pilot Test Registration Tool
Development, Adaptation, Implementation, and Maintenance of Quality Measures for the Programs of All-Inclusive Care for the Elderly (PACE) (CMS-10557)
CMS-10557
PACE Pilot Test Evaluation
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5)
GenIC #5
ESRD Grievant Satisfaction Survey
Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs
0938-1185
Stakeholder Training Forms
Health Care Payment Learning and Action Network (CMS-10559)
CMS-10559
Health Care Payment Learning and Action Network
Instrument for Soliciting Feedback on Satisfaction With, and Changes to, the Standardized Format (Medication Therapy Management Program Improvements; CMS-10396, OMB No. 0938-1154) (GenIC#6)
Beneficiary Telephone Interview Script
CMS-10396
Peer Coach Assessment
Quality Reporting Process Survey (CMS-10562)
CMS-10562
Quality Reporting Process Survey
Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project
CMS-10534
Cognitive Interview Guide, Screener and Consent Forms
Usability Testing for the Health Insurance Marketplace Websites: Health Insurance Marketplave Consumer Experiernce Surveys Project
CMS-10533
Consumer Usability Testing Guide, and Screeners
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
1,000,000
1,000,000
0
0
0
0
Annual Time Burden (Hours)
25,000
25,000
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
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:
Annual Cost to Federal Government:
$217,200
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:
William Parham 4107864669
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
12/17/2014
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