Information Collection

HHCAHPS Survey

IC 188901 under ICR 201705-0938-013 · OMB 0938-1066.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1066 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10275 HHCAHPS Survey Form
PandGManual_2017_withApps.doc Instruction
PandGManual_2017_withApps.doc Instruction
CMS-10275 Home Health Care CAHPS Survey (English) English - Surveys [Regular and Scannable].doc Form
CMS-10275 Home Health Care CAHPS Survey (Russian) Russian_2017_508_5_30_2017.doc Form
CMS-10275 Home Health Care CAHPS Survey (Spanish) Spanish_2017_5_30_2017.doc Form
CMS-10275 Home Health Care CAHPS Survey (Telephone) English - Telephone Interview Script.doc Form
CMS-10275 Home Health Care CAHPS Survey (Telephone/Proxy) English - Proxy Interview Script.doc Form
CMS-10275 Consent to Share Question #35 (English) HHCAHPS_Q35_EnglishText consent to share question.pdf Form
CMS-10275 Consent to Share Question #35 (Chinese) HHCAHPS_Q35_ChineseText consent to share questions.pdf Form
CMS-10275 Consent to Share Question #35 (Russian) HHCAHPS_Q35_RussianText consent to share question.pdf Form
CMS-10275 Consent to Share Question #35 (Traditional Chinese) HHCAHPS_Q35_Trad_Chinese consent to share question.pdf Form
CMS-10275 Consent to Share Question #35 (Vietnamese) HHCAHPS_Q35_VietnameseText consent to share question.pdf Form
English - Mail Survey Cover Letters.doc Survey Cover Letters (1st and 2nd mailings) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HHCAHPS Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10275	Home Health Care CAHPS Survey (English)	English - Surveys [Regular and Scannable].doc	No		Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Russian)	Russian_2017_508_5_30_2017.doc	No		Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Spanish)	Spanish_2017_5_30_2017.doc	No		Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Telephone)	English - Telephone Interview Script.doc	No		Fillable Printable
Form	CMS-10275	Home Health Care CAHPS Survey (Telephone/Proxy)	English - Proxy Interview Script.doc	No	No	Fillable Printable
Form	CMS-10275	Consent to Share Question #35 (English)	HHCAHPS_Q35_EnglishText consent to share question.pdf	No		Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Chinese)	HHCAHPS_Q35_ChineseText consent to share questions.pdf	No		Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Russian)	HHCAHPS_Q35_RussianText consent to share question.pdf	No		Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Traditional Chinese)	HHCAHPS_Q35_Trad_Chinese consent to share question.pdf	No		Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Vietnamese)	HHCAHPS_Q35_VietnameseText consent to share question.pdf	No		Fillable Fileable
Instruction			PandGManual_2017_withApps.doc	No		Printable Only
Instruction			PandGManual_2017_withApps.doc	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,176,699	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,176,699	-1,790,301	2,967,000
Annual IC Time Burden (Hours)	235,340	-358,060	593,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Cover Letters (1st and 2nd mailings)	English - Mail Survey Cover Letters.doc	05/31/2017

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