OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Beneficiary and Family-Centered Satisfaction Survey

IC 201543 under ICR 201707-0938-002 · OMB 0938-1177.

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

View Information Collection (IC)

Medicare Beneficiary and Family-Centered Satisfaction Survey
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10393 Attachment A: Beneficiary Experience Survey CMS-10393 11th_SOW_Beneficiary Experience Survey _Attachment_A_04 05 2017.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10393 Attachment B: Direct Follow-up CMS-10393 11th_SOW_Direct Follow Up _Attachment_B_04 05 2017.docx Yes Yes Fillable Fileable
Instruction CMS-10393 11th_SOW_Direct Follow-up Instructions_Attachment_F_04 05 2017.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10393 Attachment C: General Feedback Web Survey CMS-10393 11th_SOW_General Feedback Web survey_C_04 05 2017.docx Yes Yes Fillable Fileable
Instruction CMS-10393 11th_SOW_Telephone Instructions_Attachment_E_04 05 2017.docx Yes Yes Fillable Fileable
Instruction CMS-10393 11th_SOW_Written Survey Instructions_G_04 05 2017.docx Yes Yes Fillable Fileable
Instruction CMS-10393 11th_SOW_Web Survey Instructions_Attachment_H_04 05 2017.docx Yes Yes Fillable Fileable

Health Health Care Services

 

24,970 0
   
Individuals or Households
 
   0 %

  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 24,970 0 8,960 0 0 16,010
Annual IC Time Burden (Hours) 2,899 0 -1,104 0 0 4,003
Annual IC Cost Burden (Dollars) 31,213 0 11,200 0 0 20,013

Title Document Date Uploaded
Legislation CMS-10393 11th_SOW_Related Legislation_Attachment_D_04 05 2017.docx 07/05/2017
Crosswalk CMS-10393_Survey Crosswalk_121117_FINAL.docx 12/20/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.