In-Center Hemodialysis CAHPS Survey: National Implementation

National Implementation of In-Center Hemodialysis CAHPS Survey (CMS-10105)

Documents and Forms

Document Name Document Type
Attachment B_ICH_CoverLetter1_English.pdf Other-Sample Cover Letter (English)
Attachment B_ICH_CoverLetter1_English.pdf Other-Sample Cover Letter (English)
CMS-10105 Medicare In-Center Hemodialysis Survey (English) Attachment A_ICH CAHPS Questionnaire.pdf Form
CMS-10105 Medicare In-Center Hemodialysis Survey (English) Attachment A_ICH CAHPS Questionnaire.pdf Form

Information Collection (IC) Details

IC Title:	In-Center Hemodialysis CAHPS Survey: National Implementation	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Sample Cover Letter (English)			Attachment B_ICH_CoverLetter1_English.pdf		No		Paper Only
Form	CMS-10105	Medicare In-Center Hemodialysis Survey (English)	Attachment A_ICH CAHPS Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 103,500	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	207,000	-10,600	217,600
Annual IC Time Burden (Hours)	55,890	-2,863	58,753
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.