HCAHPS Survey

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Mode Experiment (CMS-10542)

Documents and Forms

Document Name Document Type
Form CMS-10102 HCAHPS Survey Form
HCAHPS_Cover_Letter.pdf Other-Cover Letter
CMS-10102 HCAHPS Only ARM, Mode Experiment HCAHPS Instrument 20150224.pdf Form
CMS-10542 Phone Script HCAHPS_Script.pdf Form

Information Collection (IC) Details

IC Title:	HCAHPS Survey	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
Form	CMS-10102	HCAHPS Only ARM, Mode Experiment	HCAHPS Instrument 20150224.pdf	No	Fillable Printable
Other-Cover Letter			HCAHPS_Cover_Letter.pdf	No	Fillable Printable
Form	CMS-10542	Phone Script	HCAHPS_Script.pdf	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,080	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	4,080	4,080
Annual IC Time Burden (Hours)	544	544
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.