In-Center Hemodialysis CAHPS Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10105 Attachment E - Telephone Script (English and Spanish)	Form	Modified	Available
Form CMS-10105 Attachment C - Final ICH CAHPS Survey (English and Spanish)	Form	Modified	Available
Form CMS-10105 Attachment E - Telephone Script (English and Spanish)	Form	New	Available
Form CMS-10105 Attachment C - Final ICH CAHPS Survey (English and Spanish)	Form	New	Available
CMS-10105 - Supporting Statement part B [rev 7-3-2013].docx	Supporting Statement B	Uploaded 2013-07-05	Available
Attachment A - ICH CAHPS Pilot Test Summary Report.docx	Supplementary Document	Uploaded 2013-07-05	Available
Attachment F - ICH CAHPS Pre-Notification Letter for National Implementation (English and Spanish).docx	Supplementary Document	Uploaded 2013-07-05	Available
Attachment D - ICH CAHPS Cover Letter for National Implementation (English and Spanish).docx	Supplementary Document	Uploaded 2013-07-05	Available
Attachment B - Crosswalk.docx	Supplementary Document	Uploaded 2013-07-05	Available
Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish).docx	Supplementary Document	Uploaded 2013-07-05	Repair queued
Attachment D - ICH CAHPS Cover Letter for Mode Experiment (English and Spanish).docx	Supplementary Document	Uploaded 2013-07-05	Available
CMS-10105 - Supporting Statement part A [rev 7-3-2013].docx	Supporting Statement A	Uploaded 2013-07-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8773	In-Center Hemodialysis CAHPS Survey: Mode	Form	Modified	Attachment E - Telephone Script (English and Spanish)
8773	In-Center Hemodialysis CAHPS Survey: Mode	Form	Modified	Attachment C - Final ICH CAHPS Survey (English and Spanish)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form	New	Attachment E - Telephone Script (English and Spanish)
207671	In-Center Hemodialysis CAHPS Survey: National Implementation	Form	New	Attachment C - Final ICH CAHPS Survey (English and Spanish)

ICR Details

OMB Control No: 0938-0926	ICR Reference No: 201307-0938-002
Status: Historical Active	Previous ICR Reference No: 200407-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: 19941
Title: In-Center Hemodialysis CAHPS Survey
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/20/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/09/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved
Responses	325,000	0	0
Time Burden (Hours)	87,750	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Administration of In-center Hemodialysis CAHPS(ICH CAHPS) survey by more than 5,700 Medicare-certified ESRD facilities is now required as part of the value-based purchasing program for payments under the Medicare program, as described in the 2012 proposed and final ESRD Prospective System Payment Update Rules published in the Federal Register on July 8, 2011, and November 10, 2011, respectively. Value-based purchasing promotes CMS' goals: better healthcare for individuals; better care for populations and communities; and, lower costs through improvement. Beginning in CY2014, ICH facilities will be required to contract with a CMS-approved survey vendor to implement the survey; the CMS-approved vendor shall follow a set of standardized survey administration procedures developed for national implementation. Survey results from the national implementation will be publicly reported on the DFC website on www.medicare.gov.

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Authorizing Statute(s): US Code: 42 USC 1881(h) Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 23566	04/19/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 38983	06/28/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
In-Center Hemodialysis CAHPS Survey: Mode	CMS-10105, CMS-10105	Attachment C - Final ICH CAHPS Survey (English and Spanish) ,   Attachment E - Telephone Script (English and Spanish)
In-Center Hemodialysis CAHPS Survey: National Implementation	CMS-10105, CMS-10105	Attachment C - Final ICH CAHPS Survey (English and Spanish) ,   Attachment E - Telephone Script (English and Spanish)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	325,000	0	0	325,000	0	0
Annual Time Burden (Hours)	87,750	0	0	87,750	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The field test burden was discontinued in 2007. This is a Reinstatement that adds burden associated with the mode experiment and the national implementation. While the overall burden has increased from adding the mode experiment and the national implementation, the annual (per response) burden for the mode experiment and national implementation have decreased. The hours per response for the field test were approximately .50 hr, compared to the estimated .27 hr for both the ICH CAHPS Survey mode experiment and national implementation.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/09/2013

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