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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.