Information Collection

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

IC 245297 under ICR 201904-0938-010 · OMB 0938-1370.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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	CAHPSÂ® 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 %

table that charts list of burden
	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

table that charts IC Documents
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.