Information Collection

National Implementation of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) CMS-10102

IC 202110 under ICR 201204-0938-008 · OMB 0938-0981.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0981 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10102 National Implementation of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) CMS-10102 Form and Instruction
CMS-10102 Appendix B CMS-10102_Supporting_Statement_Part_A_(Appendix_B).pdf Form and Instruction
CMS-10102 Appendix A CMS-10102_Supporting_Statement_Part_A_(Appendix_A).pdf Form and Instruction
CMS-10102 Appendix C CMS-10102_Supporting_Statement_Part_A_(Appendix_C).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	National Implementation of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) CMS-10102	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10102	Appendix B	CMS-10102_Supporting_Statement_Part_A_(Appendix_B).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	Appendix A	CMS-10102_Supporting_Statement_Part_A_(Appendix_A).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	Appendix C	CMS-10102_Supporting_Statement_Part_A_(Appendix_C).pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,812	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	3,812	3,812
Annual IC Time Burden (Hours)	3,812	3,812
Annual IC Cost Burden (Dollars)	15,248,000	15,248,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

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