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Federal forms, ICRs, and supporting documents

Information Collection

In-Center Hemodialysis CAHPS Survey: National Implementation

IC 207671 under ICR 201609-0938-014 · OMB 0938-0926.

Documents and Forms
Document Name
Document Type
Other-Pre-Notification Letter (Engli
Other-Sample Cover Letter (English a
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

In-Center Hemodialysis CAHPS Survey: National Implementation
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Pre-Notification Letter (English and Spanish) Attachment_C_ICH_CAHPS_Pre-Notification_Letter_082316.docx No   Paper Only
Other-Sample Cover Letter (English and Spanish) Attachment_D_ICH_CAHPS_Sample_Cover_Letter_051816.docx No   Paper Only
Form CMS-10105 Medicare In-Center Hemodialysis Survey (English and Spanish) Attachment_A_Final_ICH_CAHPS_Survey_051816 09-27-2016 OSORA PRA Input.docx Yes Yes Fillable Fileable

Health Health Care Services

 

109,328 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 218,656 0 0 -101,344 0 320,000
Annual IC Time Burden (Hours) 59,037 0 0 -27,363 0 86,400
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk: Survey Attachment_B_ICH_CAHPS_Survey_Crosswalk_092716.docx 09/28/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.