OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

HHCAHPS Survey

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

Documents and Forms
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IC Document
Information Collection (IC) Details

View Information Collection (IC)

HHCAHPS Survey
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted 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

Health Health Care Services

 

1,186,240 0
   
Individuals or Households
 
   0 %

  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 1,186,240 0 0 9,541 0 1,176,699
Annual IC Time Burden (Hours) 237,248 0 0 1,908 0 235,340
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.