Document Name Document Type
Form CMS-10550 Hospital National Provider Survey Form and Instruction
CMS-10550 Qualitative Interview Guide Hospital Attachment III Qualitative Interview Guide Mapping Research Question to Interview Question 2015 11 10.docx Form and Instruction
CMS-10550 Structured Research Question Mapped to Survey Questions Hospital Attachment IV Structured Survey Questions Mapped to Research Questions 2015 11 10.docx Form and Instruction
CMS-10550 Summary of Interview Hospital Attachment VI Summary of Interview Content 2015 11 10.docx Form and Instruction
CMS-10550 List of Quality and Efficiency Measures Hospital Attachment VII List of Quality and Efficiency Measures 2015 11 10.docx Form and Instruction
CMS-10550 Interview Topic Guide for Semi-Structured Interview Hospital Attachment VIII Interview Topic Guide for Semi-Structured Interview 2015 11 10.docx Form and Instruction
CMS-10550 Standardized Hospital National Provider Survey Hospital Attachment XIII Standardized Hospital National Provider Survey 2015 11 10.docx Form and Instruction
Hospital National Provider Survey List of Attachments 2015 11 10.docx List of Attachments IC Document
Hospital Attachment IX Web Survey Invitation Email 2015 11 10.docx Web Survery Invitation Email IC Document
Hospital Attachment V Recruitment email or letter 2015 11 10.docx Attachment V - Recruitment email IC Document
Hospital Attachment X First Mail Survey Letter 2015 11 10.docx Attachment X - First Mail Survey Letter IC Document
Hospital Attachment XI Reminder Letter 2015 11 10.docx Attachment XI - Reminder Letter IC Document
Hospital Attachment XII Second Survey Cover Letter 2015 11 10.docx Attqachment XII - Second Survey Cover Letter IC Document
Hospital Attachment I Development of Two National Provider Surverys 2015 11 10.docx Attachment I - Development of Two National Provider Surveys IC Document
Hospital Attachment II Data Sources Used for 2015 Impact Assessment Report 2015 11 10.docx Attachment II - Data Sources Used for 2015 Impact Assessment IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospital National Provider 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?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10550	Qualitative Interview Guide	Hospital Attachment III Qualitative Interview Guide Mapping Research Question to Interview Question 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10550	Structured Research Question Mapped to Survey Questions	Hospital Attachment IV Structured Survey Questions Mapped to Research Questions 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10550	Summary of Interview	Hospital Attachment VI Summary of Interview Content 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10550	List of Quality and Efficiency Measures	Hospital Attachment VII List of Quality and Efficiency Measures 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10550	Interview Topic Guide for Semi-Structured Interview	Hospital Attachment VIII Interview Topic Guide for Semi-Structured Interview 2015 11 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10550	Standardized Hospital National Provider Survey	Hospital Attachment XIII Standardized Hospital National Provider Survey 2015 11 10.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 940	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	940	940
Annual IC Time Burden (Hours)	639	639
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
List of Attachments	Hospital National Provider Survey List of Attachments 2015 11 10.docx	11/16/2015
Web Survery Invitation Email	Hospital Attachment IX Web Survey Invitation Email 2015 11 10.docx	11/16/2015
Attachment V - Recruitment email	Hospital Attachment V Recruitment email or letter 2015 11 10.docx	11/16/2015
Attachment X - First Mail Survey Letter	Hospital Attachment X First Mail Survey Letter 2015 11 10.docx	11/16/2015
Attachment XI - Reminder Letter	Hospital Attachment XI Reminder Letter 2015 11 10.docx	11/16/2015
Attqachment XII - Second Survey Cover Letter	Hospital Attachment XII Second Survey Cover Letter 2015 11 10.docx	11/16/2015
Attachment I - Development of Two National Provider Surveys	Hospital Attachment I Development of Two National Provider Surverys 2015 11 10.docx	11/16/2015
Attachment II - Data Sources Used for 2015 Impact Assessment	Hospital Attachment II Data Sources Used for 2015 Impact Assessment Report 2015 11 10.docx	11/16/2015

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

Hospital National Provider Survey

(CMS-10550) Hospital National Provider Survey

OMB: 0938-1290

IC ID: 217140

View Information Collection (IC)