Information Collection

National Implementation

IC 212899 under ICR 202304-0938-011 · OMB 0938-1257.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1257 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10537 National Implementation	Form and Instruction
CMS-10537 Hospice Experience of Care Survey - CAHPS Hospice Survey QAG V9.0_December 2022.pdf	Form and Instruction
CMS-10537 Hospice Experience of Care Survey - CAHPS Hospice Survey QAG V9.0_December 2022.pdf	Form and Instruction
CMS-10537 CAHPS Hospice Survey - Telephone CMS-10537 - Appendix cahps-hospice-telephone_QNR_2017.pdf	Form
CMS-10537 CAHPS Hospice Survey - Telephone CMS-10537 - Appendix cahps-hospice-telephone_QNR_2017.pdf	Form

IC Title:

National Implementation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 418

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
Form and Instruction	CMS-10537	Hospice Experience of Care Survey -	CAHPS Hospice Survey QAG V9.0_December 2022.pdf		No		Printable Only
Form	CMS-10537	CAHPS Hospice Survey - Telephone	CMS-10537 - Appendix cahps-hospice-telephone_QNR_2017.pdf		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,140,695

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	1,140,695	108,691	1,032,004
Annual IC Time Burden (Hours)	198,481	18,477	180,004
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.