Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

Forms and Documents

Document Name	Status
Form CMS-10700 User Experience Design Validation for Accessing Public Data Made Available at CMS.gov (CMS-10700) Form and Instruction	New
Form CMS-10698 Evaluating the Users Experience Accessing Public Data Made Available at CMS.gov (CMS-10698) Form and Instruction	New
Form CMS-10686 (CMS-10686) 2018 Resource Assessment Form and Instruction	New
Form CMS-10689 Evaluating the Users Experience Accessing Public Data Made Available at CMS.gov (CMS-10689) Form and Instruction	New
Form CMS-10685 (CMS-10685) E-mail Feedback Regarding Psychiatric Facility Quality Measure Strategies Form and Instruction	New
Form CMS-10683 MIPS Feedback Request: 8 Quick Multiple Choice Questions (CMS-10683) Form and Instruction	New
Form CMS-10682 Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682) Form	New
Form CMS-10679 Electronic Medical Documentation Interoperability (EMDI) Workgroup Survey Form	New
Form CMS-10676 CMS-10676.Medicare.gov Sitewide Qualtrics Survey Form and Instruction	New
Form CMS-10415 MyMedicare.gov User Satisfaction Survey Form and Instruction	New
Form CMS-10415 Medicare Plan Finder User Satisfaction Survey Form and Instruction	New
Form CMS-10415 CMS.gov User Satisfaction Survey Form and Instruction	New
Form CMS-10626 (CMS-10626) End Stage Renal Disease Quality Reporting System (EQRS) Customer Satisfaction and Task Prioritization Survey for the EQRS Release 1.0 Project. Form and Instruction	Unchanged
Form GenIC#5 End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2 Form and Instruction	Unchanged
Form CMS-10396 Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396) Form and Instruction	Unchanged
Form CMS-10590 QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590) Form and Instruction	Unchanged
Form CMS-10591 Cognitive Testing for the Marketplace Dental Survey (CMS-10591) Form and Instruction	Unchanged
Form CMS-10588 Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588) Form and Instruction	Unchanged
Form CMS-10534 Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project (CMS-10534) Form and Instruction	Unchanged
Form CMS-10415 Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs Form and Instruction	Unchanged
Form CMS-10415 Beneficiary Contact Center Customer Satisfaction Survey Form and Instruction	Unchanged
0938-1185.(GenIC#5) Sample Prenotification Letter.docx Supplementary Document	2016-11-10
0938-1185 (GenIC #5) Change Justification_ESRD Grievant Satisfaction Survey_revised -10-21-16.docx Justification for No Material/Nonsubstantive Change	2016-11-10
Pre-Notification Letter_Final (GenIC#5 - nonsub change 5-2-16) (CLEAN).pdf Supplementary Document	2016-08-05
Pre-Notification Letter_Final (GenIC#5 - nonsub change 5-2-16).pdf Supplementary Document	2016-05-02
0938-1185 Change Justification_ESRD Grievant Satisfaction Survey (GenIC#5).pdf Justification for No Material/Nonsubstantive Change	2016-05-02
CMS-10415_Supporting_Statement_Part_B.doc Supporting Statement B	2015-12-29
CMS-10415_Supporting_Statement_Part_A (4-4-16).docx Supporting Statement A	2016-04-04

IC Document Collections

IC ID	Document Title	Status
235822	User Experience Design Validation for Accessing Public Data Made Available at CMS.gov (CMS-10700) Form and Instruction	New
234781	Evaluating the Users Experience Accessing Public Data Made Available at CMS.gov (CMS-10698) Form and Instruction	New
233653	(CMS-10686) 2018 Resource Assessment Form and Instruction	New
233627	Evaluating the Users Experience Accessing Public Data Made Available at CMS.gov (CMS-10689) Form and Instruction	New
233421	(CMS-10685) E-mail Feedback Regarding Psychiatric Facility Quality Measure Strategies Form and Instruction	New
233413	MIPS Feedback Request: 8 Quick Multiple Choice Questions (CMS-10683) Form and Instruction	New
233248	Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682) Form	New
232756	Electronic Medical Documentation Interoperability (EMDI) Workgroup Survey Form	New
231881	CMS-10676.Medicare.gov Sitewide Qualtrics Survey Form and Instruction	New
227720	MyMedicare.gov User Satisfaction Survey Form and Instruction	New
227719	Medicare Plan Finder User Satisfaction Survey Form and Instruction	New
227717	CMS.gov User Satisfaction Survey Form and Instruction	New
222911	(CMS-10626) End Stage Renal Disease Quality Reporting System (EQRS) Customer Satisfaction and Task Prioritization Survey for the EQRS Release 1.0 Project. Form and Instruction	Unchanged
219438	End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2 Form and Instruction	Unchanged
219437	Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396) Form and Instruction	Unchanged
219436	QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590) Form and Instruction	Unchanged
219435	Cognitive Testing for the Marketplace Dental Survey (CMS-10591) Form and Instruction	Unchanged
219434	Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588) Form and Instruction	Unchanged
219433	Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project (CMS-10534) Form and Instruction	Unchanged
219432	Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs Form and Instruction	Unchanged
219431	Beneficiary Contact Center Customer Satisfaction Survey Form and Instruction	Unchanged

ICR Details

OMB Control No: 0938-1185	ICR Reference No: 201611-0938-004
Status: Historical Active	Previous ICR Reference No: 201605-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)
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 with change	Conclusion Date: 02/28/2017
	Date Received in OIRA: 11/10/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2019	04/30/2019	04/30/2019
Responses	1,000,000	0	1,000,000
Time Burden (Hours)	50,000	0	50,000
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: 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:
	80 FR 66904	10/30/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 81550	12/30/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 21

IC Title	Form No.	Form Name
Evaluation of Stakeholder Training - Health Insurance Marketplace and Market Stabilization Programs	CMS-10415	Stakeholder Training Forms
CMS.gov User Satisfaction Survey	CMS-10415	CMS.gov User Satisfaction Survey
Evaluating the Users Experience Accessing Public Data Made Available at CMS.gov (CMS-10689)	CMS-10689	CMS-10689. OEDA_UserResearchScriptWDDSE
MIPS Feedback Request: 8 Quick Multiple Choice Questions (CMS-10683)	CMS-10683	MIPS Feedback Request: 8 Quick Multiple Choice Questions
Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project (CMS-10534)	CMS-10534	Cognitive Interview Guide, Screener and Consent Forms
(CMS-10626) End Stage Renal Disease Quality Reporting System (EQRS) Customer Satisfaction and Task Prioritization Survey for the EQRS Release 1.0 Project.	CMS-10626	CrownWeb Facility User Survey
CMS-10676.Medicare.gov Sitewide Qualtrics Survey	CMS-10676	Medicare.gov Sitewide Qualtrics Survey
Beneficiary Contact Center Customer Satisfaction Survey	CMS-10415	IVR Phone Script for Survey
Cognitive Testing for the Marketplace Dental Survey (CMS-10591)	CMS-10591	Marketplace Dental Survey Cognitive Testing Eligibility Screener
End Stage Renal Disease (ESRD) Grievant Satisfaction Survey (IC#5) - Round 2	GenIC#5	ESRD Greivant Satisfaction Survey Version 2.0
Medicare Plan Finder User Satisfaction Survey	CMS-10415	CMS-10415. Fast Track Medicaregov - Medicare Plan Finder Survey
(CMS-10686) 2018 Resource Assessment	CMS-10686	Resource Assessment
MyMedicare.gov User Satisfaction Survey	CMS-10415	MyMedicare.gov Survey
Unmoderated Online User Testing of a Proposed New CMS.gov Website Structure (CMS-10682)	CMS-10682	CMS_OCS_TestingQuestions_SitemapTesting-updated (002).docx
Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396)	CMS-10396	Telephone Interview Script
Evaluating the Users Experience Accessing Public Data Made Available at CMS.gov (CMS-10698)	CMS-10698	Evaluating the Users Experience Accessing Public Data Made Available at CMS.gov
User Experience Design Validation for Accessing Public Data Made Available at CMS.gov (CMS-10700)	CMS-10700, CMS-10700	Wireframes for Design Validation ,   Discussion Guide
QualityNet.org and QualityNet Secure Portal Customer Satisfaction and Task Prioritization Survey for Phase 1 of the QualityNet Portal (QNP) redesign project (CMS-10590)	CMS-10590	Quality Net User Survey
(CMS-10685) E-mail Feedback Regarding Psychiatric Facility Quality Measure Strategies	CMS-10685	LAN member best practices email
Electronic Medical Documentation Interoperability (EMDI) Workgroup Survey	CMS-10679	EMDI Workgroup Participation Survey
Usability Testing and Evaluation for Phase 1 of the QualityNet Portal (QNP) Redesign Project (CMS-10588)	CMS-10588	Usability Test Script

---

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)	50,000	50,000	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: Of the original 25,000 hours that were approved, CMS used 22,261 hours. We are seeking to carryover 6,566 hours and requesting an additional 43,434 hours, for a total of 50,000 hours.

---

Annual Cost to Federal Government: $250,000

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]? Yes

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: 11/10/2016

---