Beneficiary Customer Service Feedback Survey

Forms and Documents

Document Name	Status
Form CMS-10068 Beneficiary Customer Service Feedback Survey Form and Instruction	Modified
CMS-10068.Supporting Statement - Part B.doc Supporting Statement B	2010-09-03
CMS-10068.Survey 2010 Crosswalk.doc Supplementary Document	2010-09-03
CMS-10068.Supporting Statement - Part A.doc Supporting Statement A	2010-09-03

IC Document Collections

IC ID	Document Title	Status
37921	Beneficiary Customer Service Feedback Survey Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0894	ICR Reference No: 201009-0938-007
Status: Historical Active	Previous ICR Reference No: 200605-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Beneficiary Customer Service Feedback Survey
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 without change	Conclusion Date: 11/05/2010
	Date Received in OIRA: 09/22/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2013	36 Months From Approved
Responses	2,242	0	0
Time Burden (Hours)	224	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The need for this previously OMB approved information collection is to further meet the customer service goals that the CMS has established and to continue to create a rapport within the Medicare community. DMOA will collect information several times during FY 2010-2011 to assess the customer service provided via written responses. The DMOA will conduct the written survey through mailings that will accompany actual responses.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 34740	06/18/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 54150	09/03/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Beneficiary Customer Service Feedback Survey	CMS-10068	Beneficiary Customer Service Feedback Survey

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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	2,242	0	0	2,242	0	0
Annual Time Burden (Hours)	224	0	0	224	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The agency seeks to reinstate this information collection request.

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Annual Cost to Federal Government: $6,636

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

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Common Form ICR:  No

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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: 09/22/2010

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