HCAHPS Survey (Patients)

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⚠️ Notice: This information collection may be referencing outdated material.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) 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)	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: 2,839,017	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,839,017	-265,183	3,104,200
Annual IC Time Burden (Hours)	343,047	-32,043	375,090
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.