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Federal forms, ICRs, and supporting documents

Information Collection

Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 201610-0938-003 · OMB 0938-1221.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Adult Qualified Health Plan Enrollee Experience Survey
 
No Unchanged
 
Voluntary
 
45 CFR 156.200(b)(5) 45 CFR 155.200(d)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10488 Survey Vendor Application CMS-10488 - 2016 Survey Vendor Application_071415_Clean.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10488 2017 QHP Survey (Chinese) CMS-10488 - Chinese QHP_Survey.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10488 Cover Letter (Chinese) CMS-10488 - QHP_CoverLetter_Chinese_508_071315_Final.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10488 QHP Survey (English) CMS-10488 - English_2017_QHP_Survey.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10488 Cover Letter (English) CMS-10488 - QHP_CoverLetter_English_071315_Final.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10488 QHP Survey (Spanish) CMS-10488 - Spanish 2017_QHP_Survey.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10488 Cover Letter (Spanish) CMS-10488 - QHP_CoverLetter_Spanish_508_071315_Final.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

105,015 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   50 %

  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 105,015 0 0 0 0 105,015
Annual IC Time Burden (Hours) 37,823 0 0 0 0 37,823
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-10488 - Goals of the Psychometric and Beta Test Goals CMS-10488 - Appendix A _Clean.docx 09/10/2015
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.