Medicare Health Outcomes Survey (HOS)

Medicare Health Outcomes Survey (HOS) (CMS-10203)

OMB: 0938-0701

IC ID: 203728

Information Collection (IC) Details

View Information Collection (IC)

Medicare Health Outcomes Survey (HOS)
 
No Modified
 
Voluntary
 
42 CFR 422.152

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10203 Medicare Health Outcomes Survey (HOS 3.0) Attachment B. HOS Questionnaire (English).pdf Yes Yes Fillable Printable
Form CMS-10203 Medicare Health Outcomes Survey-Modified (HOS-M) Attachment C. HOS-M Questionnaire (English).pdf Yes Yes Fillable Printable
Other-Mailing materials Attachment E. HOS Mailing Materials.pdf No   Paper Only
Other-Mailing materials Attachment F. HOS-M Mailing Materials.pdf No   Paper Only

Health Health Care Services

 

1,485 0
   
Individuals or Households
 
   34 %

  Requested 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 629,280 0 627,795 0 0 1,485
Annual IC Time Burden (Hours) 201,370 0 18,255 0 0 183,115
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Response Rates Attachment D. Response Rates.pdf 04/29/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

© 2024 OMB.report | Privacy Policy