Information Collection

Medicare Health Outcomes Survey (HOS)

IC 203728 under ICR 202104-0938-016 · OMB 0938-0701.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0701 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10203 Medicare Health Outcomes Survey (HOS)	Form
Attachment E. HOS Mailing Materials.pdf	Other-Mailing materials
Attachment F. HOS-M Mailing Materials.pdf	Other-Mailing materials
CMS-10203 Medicare Health Outcomes Survey (HOS 3.0) Attachment B. HOS Questionnaire (English).pdf	Form
CMS-10203 Medicare Health Outcomes Survey-Modified (HOS-M) Attachment C. HOS-M Questionnaire (English).pdf	Form
Attachment D. Response Rates.pdf Response Rates	IC Document

IC Title:

Medicare Health Outcomes Survey (HOS)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,485

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 34 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	629,280	627,795	1,485
Annual IC Time Burden (Hours)	201,370	18,255	183,115
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.