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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10500 Outpatient and Ambulatory Surgery Experience of Care Survey Outpatient and Ambulatory Surgery Experience of Care Survey	Form
Form CMS-1500 Telephone Interview Script for the Outpatient and Ambulatory Surgery Experience of Care Survey Outpatient and Ambulatory Surgery Experience of Care Survey	Form and Instruction
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

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10500	Yes	No	Fillable Printable
Other-Cover Letter		No		Paper Only
Form and Instruction	CMS-1500	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 %

table that charts list of burden
	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

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.

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