OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Emergency Department Patient Experience of Care Survey

IC 206749 under ICR 201305-0938-001 · OMB 0938-1209.

Documents and Forms
Document Name
Document Type
Form
Other-Telephone Script - All Version
Form
Form
Form
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Emergency Department Patient Experience of Care Survey
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10461 ER Patient Experience Survey - Admitted to Hospital Stand Alone Version 508-ATTA.DOC No No Fillable Printable
Form CMS-10461 ER Patient Experience Survey - Discharge Version 508 ATTACHMENT A ER Patient Experience Survey Discharged to community 4-25-13.docx No No Fillable Printable
Form CMS-10461 ER Patient Experience Survey - Admitted to Hospital (HCAHPS Add On) Version 508 ATTACHMENT C ER Patient Experience Survey Admitted to Hospital HCAHPS Add-on 4-25-13.docx No No Fillable Printable
Other-Telephone Script - All Versions ATTACHMENT G ER Patient Experiences Survey Telephone Script 4-25-13.doc No No Fillable Printable

Health Health Care Services

 

3,600 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,600 3,600 0 0 0 0
Annual IC Time Burden (Hours) 799 799 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Initial Letter - Discharged to Community 508 ATTACHMENT D ER Patient Experience Initial Letter Discharged To Community.pdf 04/28/2013
Initial Letter - Admitted to Hospital (stand-alone) 508 ATTACHMENT E ER Patient Experience Initial Letter Admitted Stand Alone.pdf 04/28/2013
Initial Letter - Admitted to Hospital (Hospital CAHPS supplement) 508 ATTACHMENT F ER Patient Experience Initial Letter Admitted HCAHPS Add-on.pdf 04/28/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.