HHCAHPS Participation Exemption Request (PER) Form

CAHPS Home Health Care Survey

OMB: 0938-1066

IC ID: 210204

Information Collection (IC) Details

View Information Collection (IC)

HHCAHPS Participation Exemption Request (PER) Form
 
No New
 
Required to Obtain or Retain Benefits
 

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

Health Health Care Services

 

2,000 0
   
Private Sector Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,000 0 0 0 2,000 0
Annual IC Time Burden (Hours) 1,160 0 0 0 1,160 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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