Information Collection Request

Testing of Web Survey Design and Administration for CMS Experience of Care Surveys (CMS-10694)

ICR 201904-0938-010 · OMB 0938-1370 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10694 Mail Survey Questionnaire Form and Instruction New Repair queued
Form CMS-10694 MA Survey Web Mode Field Test Form and Instruction New Repair queued
Form CMS-10694 PDP Survey Web Mode Field Test Form and Instruction New Repair queued
Form CMS-10694 MA PD Survey Web Mode Field Test Form and Instruction New Repair queued
Form CMS-10694 HCAHPS Survey Mode Form and Instruction New Available
Form CMS-10694 Survey of MA and Part D Medicare Compliance Officers on Availability of Email Address Form and Instruction New Available
Form CMS-10694 GenIC 1 CAHPS® Hospice Survey Form and Instruction New Available
Comment and Response Summary.docx Supplementary Document Uploaded 2019-04-15 Available
20190104_CMS-10694_Supp Statement B_Clean.docx Supporting Statement B Uploaded 2019-04-15 Available
30 Day_CMS-10694_Revised Supp Statement A_ CLEAN v2.docx Supporting Statement A Uploaded 2019-11-05 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
250733 GenIC #6: In-Center Hemodialysis (ICH) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Web Mode Experiment Form and Instruction NewMail Survey Questionnaire
248863 GenIC#5 Medicare Advantage (MA) and Prescription Drug Plan (PDP) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Web Mode Field Test Form and Instruction NewMA Survey Web Mode Field Test
248863 GenIC#5 Medicare Advantage (MA) and Prescription Drug Plan (PDP) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Web Mode Field Test Form and Instruction NewPDP Survey Web Mode Field Test
248863 GenIC#5 Medicare Advantage (MA) and Prescription Drug Plan (PDP) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Web Mode Field Test Form and Instruction NewMA PD Survey Web Mode Field Test
247130 Gen-IC #2 : HCAHPS Mode Experiment Form and Instruction NewHCAHPS Survey Mode
246172 GenIC #3 MA and PDP CAHPS Web Survey of Health and Drug Plans Form and Instruction NewSurvey of MA and Part D Medicare Compliance Officers on Availability of Email Address
245297 Gen-IC #1 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey Mode Experiment Form and Instruction NewCAHPS® Hospice Survey

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
11/30/2022 36 Months From Approved
75,250 0 0
17,000 0 0
928,200 0 0





Reginfo record details
5
table that charts list of burden
IC Title Form No. Form Name
Gen-IC #1 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey Mode Experiment CMS-10694 GenIC 1
Gen-IC #2 : HCAHPS Mode Experiment CMS-10694
GenIC #3 MA and PDP CAHPS Web Survey of Health and Drug Plans CMS-10694
GenIC #6: In-Center Hemodialysis (ICH) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Web Mode Experiment CMS-10694
GenIC#5 Medicare Advantage (MA) and Prescription Drug Plan (PDP) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Web Mode Field Test CMS-10694, CMS-10694, CMS-10694 ,   ,  

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 75,250 0 0 75,250 0 0
Annual Time Burden (Hours) 17,000 0 0 17,000 0 0
Annual Cost Burden (Dollars) 928,200 0 0 928,200 0 0


Reginfo record details
  No