Information Collection

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

IC 203728 under ICR 201208-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10203 Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152 Form and Instruction
CMS-10203 Medicare HOS 2013 Questionnaire (English) Attachment_4_HOS_2_5_Questionnaire_English_REVISED.pdf Form and Instruction
CMS-10203 Medicare HOS-Modified 2013 Questionnaire (English) Attachment_6_HOS_M_Questionnaire_English.pdf Form and Instruction
TOC_Revised_Package_Attachments_07252012.pdf Table of Contents IC Document
Attachment_2_Publications.pdf Publications IC Document
Attachment_5_HOS_Materials_English_and_Spanish.pdf Mailing Mater Associated with Medicare HOS (English and Spanish) IC Document
Attachment_7_HOS_M_Materials_English.pdf Mailing Material Associated with Medicare HOS-Modified (English) IC Document
Attachment_3_Response_Rate_Table.pdf Response Rate Table IC Document
Attachment_12_CMS_10203_Crosswalk.pdf Crosswalk IC Document
Attachment_8_Covariates.pdf Covariates Used in the Case Mix Adjustments of PCS and MCS Measures IC Document

Information Collection (IC) Details

View Information Collection (IC)

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

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10203	Medicare HOS 2013 Questionnaire (English)	Attachment_4_HOS_2_5_Questionnaire_English_REVISED.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10203	Medicare HOS-Modified 2013 Questionnaire (English)	Attachment_6_HOS_M_Questionnaire_English.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,352	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
Annual Number of Responses for this IC	666,120	666,120
Annual IC Time Burden (Hours)	219,820	219,820
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Table of Contents	TOC_Revised_Package_Attachments_07252012.pdf	08/14/2012
Publications	Attachment_2_Publications.pdf	08/14/2012
Mailing Mater Associated with Medicare HOS (English and Spanish)	Attachment_5_HOS_Materials_English_and_Spanish.pdf	08/14/2012
Mailing Material Associated with Medicare HOS-Modified (English)	Attachment_7_HOS_M_Materials_English.pdf	08/14/2012
Response Rate Table	Attachment_3_Response_Rate_Table.pdf	08/14/2012
Crosswalk	Attachment_12_CMS_10203_Crosswalk.pdf	08/14/2012
Covariates Used in the Case Mix Adjustments of PCS and MCS Measures	Attachment_8_Covariates.pdf	08/14/2012

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