Beneficiary Customer Service Feedback Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0894 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10068 Beneficiary Customer Service Feedback Survey Form and Instruction
CMS-10068 Beneficiary Customer Service Feedback Survey Bene Survey-English 2010 (NEW)(Plain Lang) 4-14-10.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Beneficiary Customer Service Feedback Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10068	Beneficiary Customer Service Feedback Survey	Bene Survey-English 2010 (NEW)(Plain Lang) 4-14-10.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,242	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,242	2,242
Annual IC Time Burden (Hours)	224	224
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.