Information Collection

HHCAHPS Survey

IC 188901 under ICR 202005-0938-007 · OMB 0938-1066.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1066 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10275 HHCAHPS Survey	Form
PandGManual-v12-Chapter4_Sampling.docx	Instruction
CMS-10275 Home Health Care CAHPS Survey (English) HHCAHPS_Questionnaire_English.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Russian) HHCAHPS_Questionnaire_Russian.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Spanish) HHCAHPSQuestionnaireSpanish.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Telephone) HHCAHPS_TelephoneScript_English.docx	Form
CMS-10275 Home Health Care CAHPS Survey (Telephone/Proxy) HHCAHPS_TelephoneScriptProxy_English.docx	Form
CMS-10275 Consent to Share Question #35 (English) HHCAHPS_Q35_EnglishText.pdf	Form
CMS-10275 Consent to Share Question #35 (Chinese) HHCAHPS_Questionnaire_ChineseSimplified.pdf	Form
CMS-10275 Consent to Share Question #35 (Russian) HHCAHPS_Questionnaire_Russian.pdf	Form
CMS-10275 Consent to Share Question #35 (Traditional Chinese) HHCAHPS_Questionnaire_ChineseTraditional.pdf	Form
CMS-10275 Consent to Share Question #35 (Vietnamese) HHCAHPS_Q35_VietnameseText.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Armenian) HHCAHPS_Questionnaire_Armenian.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Chinese Simplified) HHCAHPS_Questionnaire_ChineseSimplified.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Chinese Traditional) HHCAHPS_Questionnaire_ChineseTraditional.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Vietnamese) HHCAHPS_Questionnaire_Vietnamese.pdf	Form
CMS-10237 Consent to Share Question #35 (Armenian) HHCAHPS_Q35_ConsentShareMailTelephone_Armenian.pdf	Form
English - Mail Survey Cover Letters.doc Survey Cover Letters (1st and 2nd mailings)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

HHCAHPS Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	CMS-10275	Home Health Care CAHPS Survey (Telephone)	HHCAHPS_TelephoneScript_English.docx	No	Fillable Printable
Form	CMS-10275	Home Health Care CAHPS Survey (Telephone/Proxy)	HHCAHPS_TelephoneScriptProxy_English.docx	No	Fillable Printable
Form	CMS-10275	Consent to Share Question #35 (English)	HHCAHPS_Q35_EnglishText.pdf	No	Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Chinese)	HHCAHPS_Questionnaire_ChineseSimplified.pdf	No	Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Russian)	HHCAHPS_Questionnaire_Russian.pdf	No	Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Traditional Chinese)	HHCAHPS_Questionnaire_ChineseTraditional.pdf	No	Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Vietnamese)	HHCAHPS_Q35_VietnameseText.pdf	No	Fillable Fileable
Instruction			PandGManual-v12-Chapter4_Sampling.docx	No	Printable Only
Form	CMS-10275	Home Health Care CAHPS Survey (Armenian)	HHCAHPS_Questionnaire_Armenian.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Chinese Simplified)	HHCAHPS_Questionnaire_ChineseSimplified.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Chinese Traditional)	HHCAHPS_Questionnaire_ChineseTraditional.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Vietnamese)	HHCAHPS_Questionnaire_Vietnamese.pdf	No	Fillable Fileable
Form	CMS-10237	Consent to Share Question #35 (Armenian)	HHCAHPS_Q35_ConsentShareMailTelephone_Armenian.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (English)	HHCAHPS_Questionnaire_English.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Russian)	HHCAHPS_Questionnaire_Russian.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Spanish)	HHCAHPSQuestionnaireSpanish.pdf	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,186,240

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,186,240	9,541	1,176,699
Annual IC Time Burden (Hours)	237,248	1,908	235,340
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Cover Letters (1st and 2nd mailings)	English - Mail Survey Cover Letters.doc	05/31/2017

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