Information Collection

HCAHPS Survey (Patients)

IC 8843 under ICR 201505-0938-013 · OMB 0938-0981.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0981 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10102 HCAHPS Survey (Patients)	Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials Attachment A -- HCAHPS Survey Instrument (Mail) and Supporting Materials.pdf	Form and Instruction
Attachment B - Crosswalk.docx Crosswalk	IC Document

IC Title:

HCAHPS Survey (Patients)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (Mail) and Supporting Materials	Attachment A -- HCAHPS Survey Instrument (Mail) and Supporting Materials.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,100,000

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,100,000	390,000	2,710,000
Annual IC Time Burden (Hours)	413,230	51,897	361,333
Annual IC Cost Burden (Dollars)	18,875,000	2,374,597	16,500,403

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Attachment B - Crosswalk.docx	07/07/2015

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