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Federal forms, ICRs, and supporting documents

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
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid
 
No Unchanged
 
Voluntary
 

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

Health Health Care Services

 

510,000 0
   
Individuals or Households
 
   0 %

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

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.