Information Collection

In-Center Hemodialysis CAHPS Survey: Mode

IC 8773 under ICR 201307-0938-002 · OMB 0938-0926.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0926 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10105 In-Center Hemodialysis CAHPS Survey: Mode Form
CMS-10105 Attachment C - Final ICH CAHPS Survey (English and Spani Attachment C - Final ICH CAHPS Survey (English and Spanish).docx Form
CMS-10105 Attachment E - Telephone Script (English and Spanish) Attachment E - ICH CAHPS Telephone Script (English and Spanish).docx Form
Attachment D - ICH CAHPS Cover Letter for Mode Experiment (English and Spanish).docx Attachment D - Cover Letter for Mode Experiment (English and Spanish) IC Document
Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish).docx Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	In-Center Hemodialysis CAHPS Survey: Mode	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10105	Attachment C - Final ICH CAHPS Survey (English and Spanish)	Attachment C - Final ICH CAHPS Survey (English and Spanish).docx		Yes	No	Fillable Printable
Form	CMS-10105	Attachment E - Telephone Script (English and Spanish)	Attachment E - ICH CAHPS Telephone Script (English and Spanish).docx		No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 45 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	1,350	1,350
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D - Cover Letter for Mode Experiment (English and Spanish)	Attachment D - ICH CAHPS Cover Letter for Mode Experiment (English and Spanish).docx	07/05/2013
Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish)	Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish).docx	07/05/2013

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