Information Collection

Mode Experiment

IC 209906 under ICR 201807-0938-016 · OMB 0938-1240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1240 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10500 Mode Experiment	Form
CMS-10500 OAS CAHPS (Mail Survey) Attachment A - Mail Questionnaire [07-31-2018].docx	Form
CMS-10500 OAS CAHPS (Telephone Script) Attachment B - CATI Questionnaire [07-31-2018].docx	Form and Instruction
CMS-10500 OAS CAHPS (Web Survey Screenshots) Attachment C - Web Questionnaire [07-31-2018].docx	Form and Instruction
OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx Cover Letters (Mail Mode)	IC Document
OAS CAHPS ME Attachment D2-Letter Invitation for Web Survey_1st Contact.....docx Letter Invitation (Web Survey) First Contact	IC Document
OAS CAHPS ME Attachment D3-Email Invitation for Web Survey_Reminder Cont....docx E-mail Invitation (Web Survey) First Contact	IC Document
OAS CAHPS ME Attachment D4-Email Invitation for Web Survey_Reminder Cont....docx E-mail Invitation (Web Survey) Reminder	IC Document

IC Title:

Mode Experiment

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	CMS-10500	OAS CAHPS (Mail Survey)	Attachment A - Mail Questionnaire [07-31-2018].docx	No		Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS (Telephone Script)	Attachment B - CATI Questionnaire [07-31-2018].docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	OAS CAHPS (Web Survey Screenshots)	Attachment C - Web Questionnaire [07-31-2018].docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,850

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,850	3,140	4,710
Annual IC Time Burden (Hours)	1,021	409	612
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letters (Mail Mode)	OAS CAHPS NI-ME Attachment D1-Cover_Letters - Mail Mode.docx	07/31/2018
Letter Invitation (Web Survey) First Contact	OAS CAHPS ME Attachment D2-Letter Invitation for Web Survey_1st Contact.....docx	07/31/2018
E-mail Invitation (Web Survey) First Contact	OAS CAHPS ME Attachment D3-Email Invitation for Web Survey_Reminder Cont....docx	07/31/2018
E-mail Invitation (Web Survey) Reminder	OAS CAHPS ME Attachment D4-Email Invitation for Web Survey_Reminder Cont....docx	07/31/2018

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