HCAHPS Survey (Patients via Hospital Data Collection)

National Implementation of Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) (CMS-10102)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0981 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10102 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials Attachment A -- HCAHPS Survey Instrument (Mail) and Supporting Material (English).pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials Attachment A -- HCAHPS Survey Instrument (Mail) and Supporting Material (English).pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Telephone Script) Attachment B -- HCAHPS Survey Instrument (Telephone) and Supporting Material (English).pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Telephone Script) Attachment B -- HCAHPS Survey Instrument (Telephone) and Supporting Material (English).pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (AVIR Script) Attachment C -- HCAHPS Survey Instrument (Interactive Voice Response) and Supporting Material (English).pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (AVIR Script) Attachment C -- HCAHPS Survey Instrument (Interactive Voice Response) and Supporting Material (English).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	HCAHPS Survey (Patients via Hospital Data Collection)	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
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (Mail) and Supporting Materials	Attachment A -- HCAHPS Survey Instrument (Mail) and Supporting Material (English).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (Telephone Script)	Attachment B -- HCAHPS Survey Instrument (Telephone) and Supporting Material (English).pdf	No		Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (AVIR Script)	Attachment C -- HCAHPS Survey Instrument (Interactive Voice Response) and Supporting Material (English).pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,600	400	4,200
Annual IC Time Burden (Hours)	4,600	400	4,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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