Information Collection Request

National Implementation of Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) (CMS-10102)

ICR 202311-0938-009 · OMB 0938-0981 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10102 HCAHPS Survey Instrument (Mail) - Arabic Form and Instruction Modified Repair queued
Form CMS-10102 HCAHPS Survey Instrument (Mail) - Tagalog Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Instrument (Mail) - German Form and Instruction Modified Repair queued
Form CMS-10102 HCAHPS Survey Instrument (Mail) - Portuguese Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Instrument (Mail) - Vietnamese Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Instrument (Mail) - Russian Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Instrument (Mail) - Chinese Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Instrument (Mail) - Spanish Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Instrument (Telephone Script) Form and Instruction Modified Repair queued
Form CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey (Patients) Form and Instruction Modified Repair queued
Form CMS-10102 HCAHPS Survey Translation - Arabic Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Translation - Tagalog Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Translation - German Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Translation - Portuguese Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Translation - Vietnamese Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Translation - Russian Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Translation - Chinese Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Translation - Spanish Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Instrument (Telephone Script) Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials Form and Instruction Modified Available
Form CMS-10102 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction Modified Available
CMS-10102 SUPPORTING STATEMENT A.docx Supporting Statement A Uploaded 2023-11-24 Repair queued
CMS-10102 SUPPORTING STATEMENT B -.docx Supporting Statement B Uploaded 2023-11-24 Repair queued
Response to Comments - HCAHPS OMB 60 days, CMS10102, 11-6-2023.pdf Supplementary Document Uploaded 2023-11-24 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) - Arabic
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) - Tagalog
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) - German
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) - Portuguese
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) - Vietnamese
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) - Russian
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) - Chinese
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) - Spanish
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Telephone Script)
8843 HCAHPS Survey (Patients) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) and Supporting Materials
8843 HCAHPS Survey (Patients) Form and Instruction Modified
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Translation - Arabic
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Translation - Tagalog
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Translation - German
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Translation - Portuguese
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Translation - Vietnamese
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Translation - Russian
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Translation - Chinese
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Translation - Spanish
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Instrument (Telephone Script)
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction ModifiedHCAHPS Survey Instrument (Mail) and Supporting Materials
202110 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
01/31/2025 36 Months From Approved 09/30/2024
2,304,450 0 2,843,617
282,366 0 347,647
0 0 0





Reginfo record details
2
table that charts list of burden
IC Title Form No. Form Name
HCAHPS Survey (Patients via Hospital Data Collection) CMS-10102, CMS-10102, CMS-10102, CMS-10102, CMS-10102, CMS-10102, CMS-10102, CMS-10102, CMS-10102, CMS-10102 ,   ,   ,   ,   ,   ,   ,   ,   ,  
HCAHPS Survey (Patients) CMS-10102, CMS-10102, CMS-10102, CMS-10102 , CMS-10102, CMS-10102, CMS-10102 , CMS-10102, CMS-10102 , CMS-10102 ,   ,   ,   ,   ,   ,   ,   ,   ,  

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 2,304,450 2,843,617 0 0 -539,167 0
Annual Time Burden (Hours) 282,366 347,647 0 0 -65,281 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No