OMB.report

Federal forms, ICRs, and supporting documents

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 NameDocument Type
Form CMS-10694 GenIC 1
CAHPS® Hospice Survey 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

View Information Collection (IC)

layout table

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 Yes Yes Fillable Printable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 12,000 0 12,000 0 0 0
Annual IC Time Burden (Hours) 1,956 0 1,956 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Generic Supporting Statement 01/12/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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