Information Collection

HCAHPS Only

IC 215079 under ICR 201502-0938-005 · OMB 0938-1273.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10102 HCAHPS Only ARM, Mode Experiment HCAHPS Only	Form
Attachment5_HCAHPS_Cover_Letter.pdf	Other-Letters: Initial and Follow Up
CMS-10102 HCAHPS Only ARM, Mode Experiment Attachment1-HCAHPS.pdf	Form

IC Title:

HCAHPS Only

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-Letters: Initial and Follow Up					No		Paper Only
Form	CMS-10102				No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,467

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 Agency Discretion
Annual Number of Responses for this IC	1,467	1,467
Annual IC Time Burden (Hours)	195	195
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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