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

Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid (CMS-10493)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.