MSInteractive Survey Tool for www.medicare.gov

Forms and Documents

Document Name	Status
Form CMS-R-268 MSInteractive Survey Tool for www.medicare.gov Form and Instruction	Modified
Form CMS-R-268 MSInteractive Survey Tool for www.medicare.gov Form and Instruction	Modified
Supporting_Statement_Part_B_12-03-10.doc Supporting Statement B	2011-07-27
CMS-R-268.Supporting_Statement_Part_A_10-20-2011.doc Supporting Statement A	2011-10-28

IC Document Collections

IC ID	Document Title	Status
8471	MSInteractive Survey Tool for www.medicare.gov Form and Instruction	Modified
184256	MSInteractive Survey Tool for www.medicare.gov Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0756	ICR Reference No: 201107-0938-016
Status: Historical Active	Previous ICR Reference No: 200803-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: MSInteractive Survey Tool for www.medicare.gov
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/12/2011
	Date Received in OIRA: 07/28/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved
Responses	7,000	0	0
Time Burden (Hours)	1,167	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of this submission is to continue to collect information from Internet users as they exit from the Websites Medicare.gov and CMS.gov. To ensure that we gather information about user reactions to the Websites, we have developed a survey tool that users can complete when they exit either site or by accessing a link on the bottom bar on the page. The responses on this survey tool will help CMS to make appropriate changes to the Websites in the future. The survey tool contains questions about the information that visitors are seeking from the sites, the degree to which either site was useful to them, the improvements that they would like to see in the sites, and their general comments.

---

Authorizing Statute(s): PL: Pub.L. 105 - 33 .. Name of Law: BBA of 1997
  

Citations for New Statutory Requirements: None

---

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 2690	01/14/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 19775	04/08/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
MSInteractive Survey Tool for www.medicare.gov	CMS-R-268	MSIInteractive Survey tool for www.,edicare.gov
MSInteractive Survey Tool for www.medicare.gov	CMS-R-268	MSIInteractive Survey tool for www.medicare.gov

---

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	7,000	0	0	0	0	7,000
Annual Time Burden (Hours)	1,167	0	0	0	0	1,167
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: $0

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

---

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: 07/28/2011

---