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

Medicare Health Outcomes Survey (HOS) and Supporting Regulations at 42 CFR 422.152 (CMS-10203)

OMB: 0938-0701

IC ID: 203728

Information Collection (IC) Details

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Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152
 
No Modified
 
Voluntary
 
42 CFR 422.152

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

2,340 0
   
Individuals or Households
 
   34 %

  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 1,737 0 0 -664,383 0 666,120
Annual IC Time Burden (Hours) 244,187 0 0 24,367 0 219,820
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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