Information Collection

EDPEC for Admitted Patients: HCAHPS Add-on Version A

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10543 EDPEC for Admitted Patients: HCAHPS Add-on Version A EDPEC for Admitted Patients: HCAHPS Add-on Version A	Form
Form CMS-10543 EDPEC Survey Telephone Script EDPEC for Admitted Patients: HCAHPS Add-on Version A	Form and Instruction
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

IC Title:

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.	Available Electronically?	Electronic Capability
Other-Cover Letter		No	Paper Only
Form	CMS-10543	No	Fillable Printable
Form and Instruction	CMS-10543	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 %

table that charts list of burden
	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

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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