Community Care Customer Experience Survey

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Document Name Document Type
Form 2020-2900-0876-T2 Community Care Customer Experience Survey Form and Instruction
2020-2900-0876-T2 Community Care Survey Wireframes 190032 VEO Project Charter_Community Care Customer Service v4 (FINAL Signed).pdf Form and Instruction
Service Level Measurement - Community Care 062220 (002)).docx Statistical Sample Plan IC Document
A-11 Fast-Track Clearance Reques_Community Care_(005).pdf A-11 Survey Requirements Document IC Document

Information Collection (IC) Details

IC Title:	Community Care Customer Experience Survey	Agency IC Tracking Number:	2020-2900-0876-T

IC Status: New

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	2020-2900-0876-T2	Community Care Survey Wireframes	190032 VEO Project Charter_Community Care Customer Service v4 (FINAL Signed).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	54,000	54,000
Annual IC Time Burden (Hours)	2,700	2,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Statistical Sample Plan	Service Level Measurement - Community Care 062220 (002)).docx	06/29/2020
A-11 Survey Requirements Document	A-11 Fast-Track Clearance Reques_Community Care_(005).pdf	06/29/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.