Information Collection

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

IC 8327 under ICR 200701-0938-016 · OMB 0938-0701.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.