Information Collection Request

CAHPS Home Health Care Survey (CMS-10275)

ICR 202303-0938-010 · OMB 0938-1066 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10275 Participation Exemption Request (PER) Form Form Modified Available
Form CMS-10275 Participation Exemption Request (PER) Form Form Modified Repair queued
Form CMS-10237 Consent to Share Question #35 (Armenian) Form Modified Available
Form CMS-10275 Home Health Care CAHPS Survey (Vietnamese) Form Modified Available
Form CMS-10275 Home Health Care CAHPS Survey (Chinese Traditional) Form Modified Available
Form CMS-10275 Home Health Care CAHPS Survey (Chinese Simplified) Form Modified Available
Form CMS-10275 Home Health Care CAHPS Survey (Armenian) Form Modified Available
Form CMS-10275 Consent to Share Question #35 (Vietnamese) Form Modified Available
Form CMS-10275 Consent to Share Question #35 (Traditional Chinese) Form Modified Available
Form CMS-10275 Consent to Share Question #35 (Russian) Form Modified Available
Form CMS-10275 Consent to Share Question #35 (Chinese) Form Modified Available
Form CMS-10275 Consent to Share Question #35 (English) Form Modified Available
Form CMS-10275 Home Health Care CAHPS Survey (Telephone/Proxy) Form Modified Available
Form CMS-10275 Home Health Care CAHPS Survey (Telephone) Form Modified Available
Form CMS-10275 Home Health Care CAHPS Survey (Spanish) Form Modified Available
Form CMS-10275 Home Health Care CAHPS Survey (Russian) Form Modified Available
Form CMS-10275 Home Health Care CAHPS Survey (English) Form Modified Available
Form CMS-10275 HHCAHPS Survey Form Modified Repair queued
CMS-10275 - HHCAHPS Supporting Statement A final.docx Supporting Statement A Uploaded 2023-03-31 Available
Attachment C_HHCAHPS_Survey_Q31_Response_Options_Crosswalk 12-29-2022.pdf Supplementary Document Uploaded 2023-03-27 Repair queued
CMS-10275 - HHCAHPS Supporting Statement B.docx Supporting Statement B Uploaded 2023-03-27 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
210204 Participation Exemption Request (PER) Form Form ModifiedParticipation Exemption Request (PER) Form
210204 Participation Exemption Request (PER) Form Form Modified
195477 Patient Files Instruction Modified
188901 HHCAHPS Survey Form ModifiedConsent to Share Question #35 (Armenian)
188901 HHCAHPS Survey Form ModifiedHome Health Care CAHPS Survey (Vietnamese)
188901 HHCAHPS Survey Form ModifiedHome Health Care CAHPS Survey (Chinese Traditional)
188901 HHCAHPS Survey Form ModifiedHome Health Care CAHPS Survey (Chinese Simplified)
188901 HHCAHPS Survey Form ModifiedHome Health Care CAHPS Survey (Armenian)
188901 HHCAHPS Survey Form ModifiedConsent to Share Question #35 (Vietnamese)
188901 HHCAHPS Survey Form ModifiedConsent to Share Question #35 (Traditional Chinese)
188901 HHCAHPS Survey Form ModifiedConsent to Share Question #35 (Russian)
188901 HHCAHPS Survey Form ModifiedConsent to Share Question #35 (Chinese)
188901 HHCAHPS Survey Form ModifiedConsent to Share Question #35 (English)
188901 HHCAHPS Survey Form ModifiedHome Health Care CAHPS Survey (Telephone/Proxy)
188901 HHCAHPS Survey Form ModifiedHome Health Care CAHPS Survey (Telephone)
188901 HHCAHPS Survey Form ModifiedHome Health Care CAHPS Survey (Spanish)
188901 HHCAHPS Survey Form ModifiedHome Health Care CAHPS Survey (Russian)
188901 HHCAHPS Survey Form ModifiedHome Health Care CAHPS Survey (English)
188901 HHCAHPS Survey Form Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
07/31/2026 36 Months From Approved 08/31/2023
1,149,975 0 1,294,820
420,576 0 453,239
0 0 0





Reginfo record details
3
table that charts list of burden
IC Title Form No. Form Name
HHCAHPS Survey CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10237 ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,  
Participation Exemption Request (PER) Form CMS-10275
Patient Files

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,149,975 1,294,820 0 0 -144,845 0
Annual Time Burden (Hours) 420,576 453,239 0 0 -32,663 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No