OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 CMS-10203

IC 46150 under ICR 200611-0938-009 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10203-EG
Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 CMS-10203		 Form and Instruction
CMS-10203-EG HOS Questionnaire and Instructions
Attachment 4a(3).pdf 		Form and Instruction
CMS-10203 SP HOS Questionnaire and Instructions
Attachment 4b(3).pdf 		Form and Instruction
CMS 10203 CH HOS Questionnaire and Instructions
Attachment 4c(3).pdf 		Form and Instruction
CMS-10203 EGM HOS Modified Questionnaire and Ins
Attachment 6a(3).pdf 		Form and Instruction
CMS-10203 SPM HOS Modified Questionnaire and ins
Attachment 6b(3).pdf 		Form and Instruction
CMS-10203 CHM Modified HOS Questionnaire and Ins
Attachment 6c(3).pdf 		Form and Instruction
CMS-10203 Attachments TOC(2).doc
Attachment Cover Sheet		IC Document
Attachment 7a(2).pdf
Attachment 7a		IC Document
Attachment 7b(2).pdf
Attachment 7B		IC Document
Attachment 7c(2).pdf
Attachment 7c		IC Document
Attachment 8(2).pdf
Attachment 8		IC Document
Attachment 9(2).doc
Attachment 9		IC Document
Attachment 1.doc
Panel Members		IC Document
Attachment 2(2).doc
Survey Publications		IC Document
Attachment 3(2).xls
Survey Status Information		IC Document
Attachment 5a(2).pdf
Mailing Material		IC Document
Attachment 5b(2).pdf
Mailing Material		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10203-EG HOS Questionnaire and Instructions Attachment 4a(3).pdf Yes Yes Paper Only
Form and Instruction CMS-10203 SP HOS Questionnaire and Instructions Attachment 4b(3).pdf Yes Yes Paper Only
Form and Instruction CMS 10203 CH HOS Questionnaire and Instructions Attachment 4c(3).pdf Yes Yes Paper Only
Form and Instruction CMS-10203 EGM HOS Modified Questionnaire and Ins Attachment 6a(3).pdf Yes Yes Paper Only
Form and Instruction CMS-10203 SPM HOS Modified Questionnaire and ins Attachment 6b(3).pdf Yes Yes Paper Only
Form and Instruction CMS-10203 CHM Modified HOS Questionnaire and Ins Attachment 6c(3).pdf Yes Yes Paper Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested 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 320,040 0 320,040 0 0 0
Annual IC Time Burden (Hours) 105,613 0 105,613 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Attachment Cover Sheet CMS-10203 Attachments TOC(2).doc 10/27/2006
Attachment 7a Attachment 7a(2).pdf 10/27/2006
Attachment 7B Attachment 7b(2).pdf 10/27/2006
Attachment 7c Attachment 7c(2).pdf 10/27/2006
Attachment 8 Attachment 8(2).pdf 10/27/2006
Attachment 9 Attachment 9(2).doc 10/27/2006
Panel Members Attachment 1.doc 10/27/2006
Survey Publications Attachment 2(2).doc 10/27/2006
Survey Status Information Attachment 3(2).xls 10/27/2006
Mailing Material Attachment 5a(2).pdf 10/27/2006
Mailing Material Attachment 5b(2).pdf 10/27/2006
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.