Gen-IC #1 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey Mode Experiment

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

Documents and Forms

Document Name Document Type
Form CMS-10694 GenIC 1 Gen-IC #1 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey Mode Experiment Form and Instruction
CMS-10694 GenIC 1 CAHPS® Hospice Survey CAHPS Hospice Survey_QNR for testing_1-7-21.docx Form and Instruction
GenIC#1 Generic Supporting Statement CAHPS Hospice Survey.docx Generic Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Gen-IC #1 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey Mode Experiment	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10694 GenIC 1	CAHPS® Hospice Survey	CAHPS Hospice Survey_QNR for testing_1-7-21.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12,000	12,000
Annual IC Time Burden (Hours)	1,956	1,956
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Supporting Statement	GenIC#1 Generic Supporting Statement CAHPS Hospice Survey.docx	01/12/2021

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