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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.