Information Collection

In-Center Hemodialysis CAHPS Survey: National Implementation

IC 207671 under ICR 202207-0938-007 · OMB 0938-0926.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0926 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.