Information Collection

HCAHPS Survey

IC 215448 under ICR 201502-0938-011 · OMB 0938-1272.

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.