Information Collection

Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid

IC 209181 under ICR 201404-0938-010 · OMB 0938-1239.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10493 Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid	Form and Instruction
CMS-10493 Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid) CMSAdultMedicaidCAHPSEnglishCATI_script 112513_clean.docx	Form and Instruction
CMS-10493 CAHPS 5.0H Adult Questionnaire (Medicaid) 11_25_2013_CAHPS_Adult_MEDICAID_Mockup.pdf	Form and Instruction
Medicaid CAHPS Survey Postcard.SIGNED.pdf Survey Postcard	IC Document
Medicaid CAHPS Survey Notification Letter.SIGNED.pdf Survey Notification Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10493	Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid)	CMSAdultMedicaidCAHPSEnglishCATI_script 112513_clean.docx		No	No	Printable Only
Form and Instruction	CMS-10493	CAHPS 5.0H Adult Questionnaire (Medicaid)	11_25_2013_CAHPS_Adult_MEDICAID_Mockup.pdf		No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 510,000

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	510,000	510,000
Annual IC Time Burden (Hours)	170,000	170,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Postcard	Medicaid CAHPS Survey Postcard.SIGNED.pdf	11/01/2013
Survey Notification Letter	Medicaid CAHPS Survey Notification Letter.SIGNED.pdf	11/01/2013

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