Gen-IC #2 : HCAHPS 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 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

Information Collection (IC) Details

IC Title:	Gen-IC #2 : HCAHPS Mode Experiment	Agency IC Tracking Number:	CM-CPC

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	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 %

	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

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.