Information Collection

CAHPS for MIPS Survey

IC 206234 under ICR 201611-0938-001 · OMB 0938-1222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10450 CAHPS for MIPS Survey	Form and Instruction
CMS-10450 CAHPS for MIPS Survey Appendix A-English CAHPS for MIPS Survey_102816.docx	Form and Instruction
CMS-10450 CAHPS for MIPS Survey Script Appendix B- English CAHPS for MIPS Survey CATI Script_10282016.docx	Form and Instruction
CMS-10450 CAHPS for MIPS Attestation Appendix E- CAHPS for MIPS Vendor Attestation Statement_102816.docx	Form and Instruction
Appendix C- CAHPS for MIPS Initial Cover Letter_102816.docx Initial Cover Letter	IC Document
Appendix D- CAHPS for MIPS Second Cover Letter_102816.docx Second Cover Letter	IC Document
CAHPS_Survey_Crosswalk_9.13.16.doc Crosswalk	IC Document

IC Title:

CAHPS for MIPS Survey

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
Form and Instruction	CMS-10450	CAHPS for MIPS Survey Script	Appendix B- English CAHPS for MIPS Survey CATI Script_10282016.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	CAHPS for MIPS Survey	Appendix A-English CAHPS for MIPS Survey_102816.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10450	CAHPS for MIPS Attestation	Appendix E- CAHPS for MIPS Vendor Attestation Statement_102816.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 132,307

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	132,307	15,007	117,300
Annual IC Time Burden (Hours)	43,661	4,131	39,530
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Initial Cover Letter	Appendix C- CAHPS for MIPS Initial Cover Letter_102816.docx	11/01/2016
Second Cover Letter	Appendix D- CAHPS for MIPS Second Cover Letter_102816.docx	11/01/2016
Crosswalk	CAHPS_Survey_Crosswalk_9.13.16.doc	11/01/2016

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