Information Collection

Mode Experiment

IC 209906 under ICR 201505-0938-003 · OMB 0938-1240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1240 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10500 Mode Experiment	Form
OAS CAHPS_OMB_Attachment_B_Cover Letter.docx	Other-Cover Letter
CMS-10500 Outpatient and Ambulatory Surgery OAS CAHPS Survey OAS CAHPS_OMB_Attachment_A_OAS CAHPS Survey-04-21-15.docx	Form
CMS-1500 Telephone Interview Script for the Outpatient and Ambula OAS CAHPS_OMB_Attachment_C_CATI Intro Script_rev (2).docx	Form and Instruction
OAS CAHPS Crosswalk of Changes to Survey-Letter-Intro.xlsx Crosswalk	IC Document

IC Title:

Mode Experiment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-10500	Outpatient and Ambulatory Surgery OAS CAHPS Survey	OAS CAHPS_OMB_Attachment_A_OAS CAHPS Survey-04-21-15.docx	No	Fillable Printable
Other-Cover Letter			OAS CAHPS_OMB_Attachment_B_Cover Letter.docx	No	Paper Only
Form and Instruction	CMS-1500	Telephone Interview Script for the Outpatient and Ambulatory Surgery OAS CAHPS Survey	OAS CAHPS_OMB_Attachment_C_CATI Intro Script_rev (2).docx	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,710

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	Previously Approved
Annual Number of Responses for this IC	4,710	2,406	2,304
Annual IC Time Burden (Hours)	612	228	384
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	OAS CAHPS Crosswalk of Changes to Survey-Letter-Intro.xlsx	05/06/2015

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