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⚠️ Notice: This information collection may be referencing outdated material.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
UPD Attachment 4a - 12022010 HOS 2011 English Questionnaire FINAL.pdf Other-Other: Medicare HOS - Modified
UPD Attachment 4b - 12072010 HOS 2011 Spanish Questionnaire.pdf Other- Other: Medicare HOS - Modifie
UPD Attachment 4c - 12082010 HOS 2011 Chinese Questionnaire.pdf Other- Other: Medicare HOS - Modifie
UPD Attachment 6a - 12022010 HOS-M 2011 English Questionnaire.pdf Other- Other: Other: Medicare HOS -
UPD Attachment 6b - 12072010 HOS-M Questionnaire Spanish.pdf Other- Other: Other: Medicare HOS -
UPD Attachment 6c - HOS-M 2011 Chinese Questionnaire_Revised Dec 2010 (2).pdf Other- Other: Other: Medicare HOS -
Attachment3.pdf Attachment3 IC Document
Attachment1.pdf Attachment1 IC Document
Attachment2.pdf Attachment2 IC Document
Attachment5a.pdf Attachment5a IC Document
Attachment8.pdf Attachment8 IC Document
AttachmentsTOC.pdf AttachmentsTOC IC Document
Attachment5b.pdf Attachment5b IC Document
Attachment7a.pdf Attachment7a IC Document
Attachment7b.pdf Attachment7b IC Document
Attachment7c.pdf Attachment7c 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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Other: Medicare HOS - Modified 2010 Questionnaire: English	UPD Attachment 4a - 12022010 HOS 2011 English Questionnaire FINAL.pdf	Yes	Yes	Paper Only
Other- Other: Medicare HOS - Modified 2010 Questionnaire: Spanish	UPD Attachment 4b - 12072010 HOS 2011 Spanish Questionnaire.pdf	Yes	Yes	Paper Only
Other- Other: Medicare HOS - Modified 2010 Questionnaire: Chinese	UPD Attachment 4c - 12082010 HOS 2011 Chinese Questionnaire.pdf	Yes	Yes	Paper Only
Other- Other: Other: Medicare HOS - Modified 2010 Questionnaire: English	UPD Attachment 6a - 12022010 HOS-M 2011 English Questionnaire.pdf	Yes	Yes	Paper Only
Other- Other: Other: Medicare HOS - Modified 2010 Questionnaire: Chinese	UPD Attachment 6c - HOS-M 2011 Chinese Questionnaire_Revised Dec 2010 (2).pdf	Yes	Yes	Paper Only
Other- Other: Other: Medicare HOS - Modified 2010 Questionnaire: Spanish	UPD Attachment 6b - 12072010 HOS-M Questionnaire Spanish.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,099,560	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	Previously Approved
Annual Number of Responses for this IC	1,099,560	779,520	320,040
Annual IC Time Burden (Hours)	366,520	260,907	105,613
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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