Information Collection

Outpatient and Ambulatory Surgery Experience of Care Survey

IC 209906 under ICR 201312-0938-022 · OMB 0938-1240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1240 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10500 Outpatient and Ambulatory Surgery Experience of Care Survey Form
Attachment_B_Cover Letter for First Mailing [5-13-2014].docx Other-Cover Letter
CMS-10500 Outpatient and Ambulatory Surgery Experience of Care Sur Outpatient and Ambulatory Surgery Experience of Care Survey_Draft_to_OMB_post_60-day_notice_revisions [rev 12-27-13 by OSORA PRA Form
CMS-1500 Telephone Interview Script for the Outpatient and Ambula Attachment_C_Introductory Script for Telephone Contact [5-13-2014].docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Outpatient and Ambulatory Surgery 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	CMS-10500	Outpatient and Ambulatory Surgery Experience of Care Survey	Outpatient and Ambulatory Surgery Experience of Care Survey_Draft_to_OMB_post_60-day_notice_revisions [rev 12-27-13 by OSORA PRA].docx	Yes	No	Fillable Printable
Other-Cover Letter			Attachment_B_Cover Letter for First Mailing [5-13-2014].docx	No		Paper Only
Form and Instruction	CMS-1500	Telephone Interview Script for the Outpatient and Ambulatory Surgery Experience of Care Survey	Attachment_C_Introductory Script for Telephone Contact [5-13-2014].docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,304	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	2,304	2,304
Annual IC Time Burden (Hours)	384	384
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.