Information Collection

English - Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 201402-0938-007 · OMB 0938-1221.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1221 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10488 English - Adult Qualified Health Plan Enrollee Experience Survey Form and Instruction
CMS-10488 English - Adult Qualified Health Plan Enrollee Experienc English Adult QHP Enrollee Experience Survey after OMB NCHS review_clean_2-5-14_CMS.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	English - Adult Qualified Health Plan Enrollee Experience Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 156.200(b)(5) 45 CFR 155.200(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10488	English - Adult Qualified Health Plan Enrollee Experience Survey	English Adult QHP Enrollee Experience Survey after OMB NCHS review_clean_2-5-14_CMS.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 604,240	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
Annual Number of Responses for this IC	604,240	604,240
Annual IC Time Burden (Hours)	271,930	271,930
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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