Information Collection

HHCAHPS Participation Exemption Request (PER) Form

IC 210204 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⚠️ Notice: This information collection may be referencing outdated material.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 HHCAHPS Participation Exemption Request (PER) Form Form
CMS-10275 Participation Exemption Request (PER) Form Participation Exemption Request Form.mht Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HHCAHPS Participation Exemption Request (PER) Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10275	Participation Exemption Request (PER) Form	Participation Exemption Request Form.mht		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	1,160	1,160
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.