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In-Center Hemodialysis CAHPS Survey: Mode
In-Center Hemodialysis CAHPS Survey (CMS-10105)
OMB: 0938-0926
IC ID: 8773
OMB.report
HHS/CMS
OMB 0938-0926
ICR 201609-0938-014
IC 8773
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0926 can be found here:
2022-07-18 - Extension without change of a currently approved collection
2019-11-19 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
Form CMS-10105
In-Center Hemodialysis CAHPS Survey: Mode
Form
CMS-10105 Attachment C - Final ICH CAHPS Survey (English and Spani
Attachment C - Final ICH CAHPS Survey (English and Spanish).docx
Form
CMS-10105 Attachment E - Telephone Script (English and Spanish)
Attachment E - ICH CAHPS Telephone Script (English and Spanish).docx
Form
Attachment D - ICH CAHPS Cover Letter for Mode Experiment (English and Spanish).docx
Attachment D - Cover Letter for Mode Experiment (English and Spanish)
IC Document
Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish).docx
Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish)
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
In-Center Hemodialysis CAHPS Survey: Mode
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Removed
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10105
Attachment C - Final ICH CAHPS Survey (English and Spanish)
Attachment C - Final ICH CAHPS Survey (English and Spanish).docx
Yes
No
Fillable Printable
Form
CMS-10105
Attachment E - Telephone Script (English and Spanish)
Attachment E - ICH CAHPS Telephone Script (English and Spanish).docx
No
No
Printable Only
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:
5,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
45 %
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
0
0
-5,000
0
0
5,000
Annual IC Time Burden (Hours)
0
0
-1,350
0
0
1,350
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment D - Cover Letter for Mode Experiment (English and Spanish)
Attachment D - ICH CAHPS Cover Letter for Mode Experiment (English and Spanish).docx
07/05/2013
Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish)
Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish).docx
07/05/2013
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.