Information Collection

EDPEC for Admitted Patients: HCAHPS Add-on Version A

IC 215080 under ICR 201502-0938-005 · OMB 0938-1273.

Documents and Forms

Document Name Document Type
Attachment6-EDPEC HCAHPS Add_on Version A and B-Ltr.pdf Other-Cover Letter
CMS-10543 EDPEC for Admitted Patients: HCAHPS Add-on Version A Attachment2-EDPEC HCAHPS Add-on Version A .pdf Form
CMS-10543 EDPEC Survey Telephone Script Attachment7-EDPEC PHONE SCRIPTS-ALL VERSIONS.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EDPEC for Admitted Patients: HCAHPS Add-on Version A	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Other-Cover Letter			Attachment6-EDPEC HCAHPS Add_on Version A and B-Ltr.pdf	No	Paper Only
Form	CMS-10543	EDPEC for Admitted Patients: HCAHPS Add-on Version A	Attachment2-EDPEC HCAHPS Add-on Version A .pdf	No	Fillable Printable
Form and Instruction	CMS-10543	EDPEC Survey Telephone Script	Attachment7-EDPEC PHONE SCRIPTS-ALL VERSIONS.pdf	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,454	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,454	1,454
Annual IC Time Burden (Hours)	297	297
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.