Information Collection

CAHPS Home Health Care Survey (CMS-10275)

IC 188901 under ICR 201401-0938-015 · OMB 0938-1066.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1066 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10275 CAHPS Home Health Care Survey (CMS-10275) Form
CMS-10275 Home Health Care CAHPS Survey (English) HHCAHPS_Questionnaire_English.pdf Form
CMS-10275 Home Health Care CAHPS Survey (Russian) HHCAHPS_Questionnaire_Russian.pdf Form
CMS-10275 Home Health Care CAHPS Survey (Spanish) HHCAHPS_Questionnaire_Spanish.pdf Form
CMS-10275 Home Health Care CAHPS Survey (Telephone) HHCAHPS_TelephoneScript_English.pdf Form
CMS-10275 Home Health Care CAHPS Survey (Telephone/Proxy) HHCAHPS_TelephoneScriptProxy_English.pdf Form
HHCAHPS_LeadLetter1_English.pdf HHCAHPS_LeadLetter1_English IC Document
HHCAHPS_LeadLetter2_English.pdf HHCAHPS_LeadLetter2_English IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CAHPS Home Health Care Survey (CMS-10275)	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10275	Home Health Care CAHPS Survey (English)	HHCAHPS_Questionnaire_English.pdf	Yes	Yes	Fillable Printable
Form	CMS-10275	Home Health Care CAHPS Survey (Russian)	HHCAHPS_Questionnaire_Russian.pdf	Yes	Yes	Fillable Printable
Form	CMS-10275	Home Health Care CAHPS Survey (Spanish)	HHCAHPS_Questionnaire_Spanish.pdf	Yes	Yes	Fillable Printable
Form	CMS-10275	Home Health Care CAHPS Survey (Telephone)	HHCAHPS_TelephoneScript_English.pdf	No	No	Fillable Printable
Form	CMS-10275	Home Health Care CAHPS Survey (Telephone/Proxy)	HHCAHPS_TelephoneScriptProxy_English.pdf	No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,967,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,967,000	261,000	2,706,000
Annual IC Time Burden (Hours)	593,400	52,200	541,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
HHCAHPS_LeadLetter1_English	HHCAHPS_LeadLetter1_English.pdf	01/24/2014
HHCAHPS_LeadLetter2_English	HHCAHPS_LeadLetter2_English.pdf	01/24/2014

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