Information Collection

Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152

IC 203728 under ICR 201405-0938-005 · OMB 0938-0701.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0701 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10203 Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152	Form
Attachment_E_Mailing_Materials.pdf	Other-Mailing materials
CMS-10203 Medicare Health Outcomes Survey (HOS 3.0) Attachment_C_HOS_Proposed_Questionnaire.pdf	Form
CMS-10203 Medicare Health Outcomes Survey-Modified (HOS-M) Attachment_D_HOSM_Questionnaire.pdf	Form
Attachment_B_Response_Rates.pdf Response Rates	IC Document
Attachment_A_Crosswalk_of_Changes_to_HOS_Proposed_Questionnaire.pdf Crosswalk	IC Document

IC Title:

Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10203	Medicare Health Outcomes Survey (HOS 3.0)	Attachment_C_HOS_Proposed_Questionnaire.pdf	Yes	Yes	Fillable Printable
Form	CMS-10203	Medicare Health Outcomes Survey-Modified (HOS-M)	Attachment_D_HOSM_Questionnaire.pdf	Yes	Yes	Fillable Printable
Other-Mailing materials			Attachment_E_Mailing_Materials.pdf	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,340

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 34 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,737	-664,383	666,120
Annual IC Time Burden (Hours)	244,187	24,367	219,820
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Response Rates	Attachment_B_Response_Rates.pdf	05/20/2014
Crosswalk	Attachment_A_Crosswalk_of_Changes_to_HOS_Proposed_Questionnaire.pdf	05/20/2014

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