Information Collection

HOS Field Test

IC 263064 under ICR 202310-0938-006 · OMB 0938-1464.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1464 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10861 HOS Field Test	Form and Instruction
CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questio CMS HOS Attachment A.pdf	Form and Instruction
CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questio CMS HOS Attachment A.pdf	Form and Instruction
CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questio CMS HOS Attachment B.pdf	Form and Instruction
CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questio CMS HOS Attachment B.pdf	Form and Instruction
CMS-10861 HOS Field Test Item Differences by Questionnaire CMS HOS Attachment C.pdf	Form and Instruction
CMS-10861 HOS Field Test Item Differences by Questionnaire CMS HOS Attachment C.pdf	Form and Instruction

IC Title:

HOS Field Test

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10861	Medicare Health Outcomes Survey (HOS) Field Test Questionnaire Version A	CMS HOS Attachment A.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10861	Medicare Health Outcomes Survey (HOS) Field Test Questionnaire Version B	CMS HOS Attachment B.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10861	HOS Field Test Item Differences by Questionnaire	CMS HOS Attachment C.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Health Plan Management System (HPMS)

FR Citation: 83 FR 6591

Number of Respondents: 136

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	6,800	6,800
Annual IC Time Burden (Hours)	2,267	2,267
Annual IC Cost Burden (Dollars)	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.