Information Collection

HCAHPS Survey (Patients via Hospital Data Collection)

IC 202110 under ICR 201705-0938-003 · OMB 0938-0981.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0981 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10102 HCAHPS Survey (Patients via Hospital Data Collection)	Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials CMS-10102 HCAHPS V12.0 Appendix A - HCAHPS Mail Survey Materials (Non-sub change 4-26-17).pdf	Form and Instruction
Attachment B - Crosswalk.docx Crosswalk	IC Document
CMS-10102 HCAHPS survey crosswalk (Non-sub change 4-26-17).doc CMS-10102 crosswak	IC Document

IC Title:

HCAHPS Survey (Patients via Hospital Data Collection)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (Mail) and Supporting Materials	CMS-10102 HCAHPS V12.0 Appendix A - HCAHPS Mail Survey Materials (Non-sub change 4-26-17).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,200	4,200
Annual IC Time Burden (Hours)	4,200	4,200
Annual IC Cost Burden (Dollars)	16,800,000	16,800,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Attachment B - Crosswalk.docx	07/07/2015
CMS-10102 crosswak	CMS-10102 HCAHPS survey crosswalk (Non-sub change 4-26-17).doc	05/04/2017

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