Hospice Experience of Care Survey

Documents and Forms

Document Name Document Type
Form CMS-10475 Hospice Experience of Care Survey Form and Instruction
508_Hospice_Survey_Attachment D_Survey Cover Letter.pdf Other-HOSPICE SURVEY COVER LETTER
508_Hospice_Survey_Attachment E_Telephone Consent Script DRAFT 2013_5_30.pdf Other-Hospice Experience Survey (Tel
CMS-10475 Hospice Experience Survey - Home Version 508_Hospice_Survey_Attachment A_HOME REVISED 2013_5_30.pdf Form and Instruction
CMS-10475 Hospice Experience Survey - Nursing Home Version 508_Hospice_Survey_Attachment B_NURSING HOME REVISED 2013_5_30.pdf Form and Instruction
CMS-10475 Hospice Experience Survey - Inpatient Version 508_Hospice_Survey_Attachment C_INPATIENT REVISED 2013_5_30.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospice 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 and Instruction	CMS-10475	Hospice Experience Survey - Home Version	508_Hospice_Survey_Attachment A_HOME REVISED 2013_5_30.pdf	No	No	Fillable Printable
Form and Instruction	CMS-10475	Hospice Experience Survey - Nursing Home Version	508_Hospice_Survey_Attachment B_NURSING HOME REVISED 2013_5_30.pdf	No	No	Fillable Printable
Form and Instruction	CMS-10475	Hospice Experience Survey - Inpatient Version	508_Hospice_Survey_Attachment C_INPATIENT REVISED 2013_5_30.pdf	No	No	Fillable Printable
Other-HOSPICE SURVEY COVER LETTER			508_Hospice_Survey_Attachment D_Survey Cover Letter.pdf	No	No	Printable Only
Other-Hospice Experience Survey (Telephone Script)			508_Hospice_Survey_Attachment E_Telephone Consent Script DRAFT 2013_5_30.pdf	No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 730	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	730	730
Annual IC Time Burden (Hours)	185	185
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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