Information Collection

In-Center Hemodialysis CAHPS Survey: National Implementation

IC 207671 under ICR 201908-0938-009 · OMB 0938-0926.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0926 can be found here:

Documents and Forms

Document Name Document Type
Attachment_C_ICH_CAHPS_Pre-Notification_Letter_041019.pdf Other-Pre-Notification Letter (Engli
Attachment_D_ICH_CAHPS_Sample_Cover_Letter_041019.pdf Other-Sample Cover Letter (English a
CMS-10105 Medicare In-Center Hemodialysis Survey (English and Span Attachment_A_Final_ICH_CAHPS_Survey_041619.pdf Form
Attachment_B_ICH_CAHPS_Survey_Crosswalk_041019.pdf Crosswalk IC Document
Attachment_E_Mode Experiment_Patient_Mix_Adjustment_041019.pdf Mode Experiment_Patient_Mix_Adjustment IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	In-Center Hemodialysis CAHPS Survey: National Implementation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Pre-Notification Letter (English and Spanish)			Attachment_C_ICH_CAHPS_Pre-Notification_Letter_041019.pdf	No		Paper Only
Other-Sample Cover Letter (English and Spanish)			Attachment_D_ICH_CAHPS_Sample_Cover_Letter_041019.pdf	No		Paper Only
Form	CMS-10105	Medicare In-Center Hemodialysis Survey (English and Spanish)	Attachment_A_Final_ICH_CAHPS_Survey_041619.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 108,800	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	Previously Approved
Annual Number of Responses for this IC	217,600	-1,056	218,656
Annual IC Time Burden (Hours)	58,753	-284	59,037
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Attachment_B_ICH_CAHPS_Survey_Crosswalk_041019.pdf	08/26/2019
Mode Experiment_Patient_Mix_Adjustment	Attachment_E_Mode Experiment_Patient_Mix_Adjustment_041019.pdf	08/26/2019

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