Information Collection

Hospice Experience of Care Survey

IC 207312 under ICR 201306-0938-006 · OMB 0938-1208.

Documents and Forms

Documents and forms in this information collection
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

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 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 %

table that charts list of burden
	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

table that charts IC Documents
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.