Information Collection

Gen-IC #2 : HCAHPS Mode Experiment

IC 247130 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 Gen-IC #2 : HCAHPS Mode Experiment	Form and Instruction
CMS-10694 HCAHPS Survey Mode HCAHPS Survey for Mode Experiment.docx	Form and Instruction
GenIC#2 Generic Supporting Statement Testing of Web Survey.docx Generic Supporting Statement	IC Document

IC Title:

Agency IC Tracking Number:

CM-CPC

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	HCAHPS Survey Mode	HCAHPS Survey for Mode Experiment.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,801

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,801	7,801
Annual IC Time Burden (Hours)	1,398	1,398
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	GenIC#2 Generic Supporting Statement Testing of Web Survey.docx	05/03/2021

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