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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0701 can be found here:

Documents and Forms

Document Name Document 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 English Attachment 4a(2).pdf Form and Instruction
CMS-10203 SP HOS Questionnaire Spanish Attachment 4b(2).pdf Form and Instruction
CMS-10203 CH HOS Questionnaire Chinese Attachment 4c(2).pdf Form and Instruction
CMS-10203 EGM HOS Modified Questionnaire English Attachment 6a(2).pdf Form and Instruction
CMS-10203 SPM HOS Modified Questionnaire Spanish Attachment 6b(2).pdf Form and Instruction
CMS-10203 CHM HOS Modified Questionnaire Chinese Attachment 6c(2).pdf Form and Instruction
Attachment 3(2).xls Response Rate Table IC Document

Information Collection (IC) Details

IC Title:	Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10203 EG	HOS Questionnaire English	Attachment 4a(2).pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10203 SP	HOS Questionnaire Spanish	Attachment 4b(2).pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10203 CH	HOS Questionnaire Chinese	Attachment 4c(2).pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10203 EGM	HOS Modified Questionnaire English	Attachment 6a(2).pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10203 SPM	HOS Modified Questionnaire Spanish	Attachment 6b(2).pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10203 CHM	HOS Modified Questionnaire Chinese	Attachment 6c(2).pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 320,040	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	320,040	318,471	1,569
Annual IC Time Burden (Hours)	105,613	-323,985	429,598
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Response Rate Table	Attachment 3(2).xls	01/24/2007

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