Information Collection

HCAHPS Survey (Patients via Hospital Data Collection)

IC 202110 under ICR 201903-0938-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Mail Survey Materials (English) 11-21-18.pdf	Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Telephone Script) CMS-10102 Telephone Script (English)11-21-18 .pdf	Form and Instruction
CMS-10102 HCAHPS Survey Instrument (AVIR Script) CMS-10102 AIVR Script (English) 11-21-18.pdf	Form and Instruction
CMS-10102 Crosswalk 11-27-18.xlsx Crosswalk	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (Mail) and Supporting Materials	CMS-10102 Mail Survey Materials (English) 11-21-18.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (Telephone Script)	CMS-10102 Telephone Script (English)11-21-18 .pdf	No		Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (AVIR Script)	CMS-10102 AIVR Script (English) 11-21-18.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: Businesses or other for-profits, Not-for-profit institutions

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)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS-10102 Crosswalk 11-27-18.xlsx	03/15/2019

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