Emergency Department Patient Experience of Care Survey

Emergency Room Patient Experiences with Care Survey

Documents and Forms

Document Name Document Type
Form CMS-10461 Emergency Department Patient Experience of Care Survey Form
ATTACHMENT G ER Patient Experiences Survey Telephone Script 4-25-13.doc Other-Telephone Script - All Version
CMS-10461 ER Patient Experience Survey - Admitted to Hospital Stan 508-ATTA.DOC Form
CMS-10461 ER Patient Experience Survey - Discharge Version 508 ATTACHMENT A ER Patient Experience Survey Discharged to community 4-25-13.docx Form
CMS-10461 ER Patient Experience Survey - Admitted to Hospital (HCA 508 ATTACHMENT C ER Patient Experience Survey Admitted to Hospital HCAHPS Add-on 4-25-13.docx Form
508 ATTACHMENT D ER Patient Experience Initial Letter Discharged To Community.pdf Initial Letter - Discharged to Community IC Document
508 ATTACHMENT E ER Patient Experience Initial Letter Admitted Stand Alone.pdf Initial Letter - Admitted to Hospital (stand-alone) IC Document
508 ATTACHMENT F ER Patient Experience Initial Letter Admitted HCAHPS Add-on.pdf Initial Letter - Admitted to Hospital (Hospital CAHPS supplement) IC Document

Information Collection (IC) Details

IC Title:	Emergency Department Patient Experience of Care Survey	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	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,600	3,600
Annual IC Time Burden (Hours)	799	799
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.