Information Collection

In-Center Hemodialysis CAHPS Survey: National Implementation

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0926 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_C_ICH_CAHPS_Pre-Notification_Letter_082316.docx	Other-Pre-Notification Letter (Engli
Attachment_D_ICH_CAHPS_Sample_Cover_Letter_051816.docx	Other-Sample Cover Letter (English a
CMS-10105 Medicare In-Center Hemodialysis Survey (English and Span Attachment_A_Final_ICH_CAHPS_Survey_051816 09-27-2016 OSORA PRA Input.docx	Form
Attachment_B_ICH_CAHPS_Survey_Crosswalk_092716.docx Crosswalk: Survey	IC Document

IC Title:

In-Center Hemodialysis CAHPS Survey: National Implementation

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?	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 109,328

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	218,656	-101,344	320,000
Annual IC Time Burden (Hours)	59,037	-27,363	86,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.