Information Collection

Emergency Department Patient Experience of Care Survey

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.