Information Collection

HHCAHPS Survey

IC 188901 under ICR 202303-0938-010 · OMB 0938-1066.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1066 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10275 HHCAHPS Survey	Form
Attachment D_ P and G Manual-Chapter4_Sampling_12_29_2022.pdf	Instruction
Attachment D_ P and G Manual-Chapter4_Sampling_12_29_2022.pdf	Instruction
CMS-10275 Home Health Care CAHPS Survey (English) Attachment A_ HHCAHPS_Survey_questionnaire_12_29_2022.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (English) Attachment A_ HHCAHPS_Survey_questionnaire_12_29_2022.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Russian) HHCAHPS_Questionnaire_Russian.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Russian) HHCAHPS_Questionnaire_Russian.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Spanish) HHCAHPSQuestionnaireSpanish.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Spanish) HHCAHPSQuestionnaireSpanish.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Telephone) HHCAHPS_TelephoneScript_English.docx	Form
CMS-10275 Home Health Care CAHPS Survey (Telephone) HHCAHPS_TelephoneScript_English.docx	Form
CMS-10275 Home Health Care CAHPS Survey (Telephone/Proxy) HHCAHPS_TelephoneScriptProxy_English.docx	Form
CMS-10275 Home Health Care CAHPS Survey (Telephone/Proxy) HHCAHPS_TelephoneScriptProxy_English.docx	Form
CMS-10275 Consent to Share Question #35 (English) HHCAHPS_Q35_EnglishText.pdf	Form
CMS-10275 Consent to Share Question #35 (English) HHCAHPS_Q35_EnglishText.pdf	Form
CMS-10275 Consent to Share Question #35 (Chinese) HHCAHPS_Questionnaire_ChineseSimplified.pdf	Form
CMS-10275 Consent to Share Question #35 (Chinese) HHCAHPS_Questionnaire_ChineseSimplified.pdf	Form
CMS-10275 Consent to Share Question #35 (Russian) HHCAHPS_Questionnaire_Russian.pdf	Form
CMS-10275 Consent to Share Question #35 (Russian) HHCAHPS_Questionnaire_Russian.pdf	Form
CMS-10275 Consent to Share Question #35 (Traditional Chinese) HHCAHPS_Questionnaire_ChineseTraditional.pdf	Form
CMS-10275 Consent to Share Question #35 (Traditional Chinese) HHCAHPS_Questionnaire_ChineseTraditional.pdf	Form
CMS-10275 Consent to Share Question #35 (Vietnamese) HHCAHPS_Q35_VietnameseText.pdf	Form
CMS-10275 Consent to Share Question #35 (Vietnamese) HHCAHPS_Q35_VietnameseText.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Armenian) HHCAHPS_Questionnaire_Armenian.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Armenian) HHCAHPS_Questionnaire_Armenian.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Chinese Simplified) HHCAHPS_Questionnaire_ChineseSimplified.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Chinese Simplified) HHCAHPS_Questionnaire_ChineseSimplified.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Chinese Traditional) HHCAHPS_Questionnaire_ChineseTraditional.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Chinese Traditional) HHCAHPS_Questionnaire_ChineseTraditional.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Vietnamese) HHCAHPS_Questionnaire_Vietnamese.pdf	Form
CMS-10275 Home Health Care CAHPS Survey (Vietnamese) HHCAHPS_Questionnaire_Vietnamese.pdf	Form
CMS-10237 Consent to Share Question #35 (Armenian) HHCAHPS_Q35_ConsentShareMailTelephone_Armenian.pdf	Form
CMS-10237 Consent to Share Question #35 (Armenian) HHCAHPS_Q35_ConsentShareMailTelephone_Armenian.pdf	Form
English - Mail Survey Cover Letters.doc Survey Cover Letters (1st and 2nd mailings)	IC Document
English - Mail Survey Cover Letters.doc Survey Cover Letters (1st and 2nd mailings)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

HHCAHPS Survey

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	Available Electronically?	Electronic Capability
Form	CMS-10275	Home Health Care CAHPS Survey (English)	Attachment A_ HHCAHPS_Survey_questionnaire_12_29_2022.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Russian)	HHCAHPS_Questionnaire_Russian.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Spanish)	HHCAHPSQuestionnaireSpanish.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Telephone)	HHCAHPS_TelephoneScript_English.docx	No	Fillable Printable
Form	CMS-10275	Home Health Care CAHPS Survey (Telephone/Proxy)	HHCAHPS_TelephoneScriptProxy_English.docx	No	Fillable Printable
Form	CMS-10275	Consent to Share Question #35 (English)	HHCAHPS_Q35_EnglishText.pdf	No	Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Chinese)	HHCAHPS_Questionnaire_ChineseSimplified.pdf	No	Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Russian)	HHCAHPS_Questionnaire_Russian.pdf	No	Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Traditional Chinese)	HHCAHPS_Questionnaire_ChineseTraditional.pdf	No	Fillable Fileable
Form	CMS-10275	Consent to Share Question #35 (Vietnamese)	HHCAHPS_Q35_VietnameseText.pdf	No	Fillable Fileable
Instruction			Attachment D_ P and G Manual-Chapter4_Sampling_12_29_2022.pdf	No	Printable Only
Form	CMS-10275	Home Health Care CAHPS Survey (Armenian)	HHCAHPS_Questionnaire_Armenian.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Chinese Simplified)	HHCAHPS_Questionnaire_ChineseSimplified.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Chinese Traditional)	HHCAHPS_Questionnaire_ChineseTraditional.pdf	No	Fillable Fileable
Form	CMS-10275	Home Health Care CAHPS Survey (Vietnamese)	HHCAHPS_Questionnaire_Vietnamese.pdf	No	Fillable Fileable
Form	CMS-10237	Consent to Share Question #35 (Armenian)	HHCAHPS_Q35_ConsentShareMailTelephone_Armenian.pdf	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,043,447

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	1,043,447	-142,793	1,186,240
Annual IC Time Burden (Hours)	208,689	-28,559	237,248
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Cover Letters (1st and 2nd mailings)	English - Mail Survey Cover Letters.doc	05/31/2017

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