HCAHPS Survey (Patients via Hospital Data Collection)

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

OMB: 0938-0981

IC ID: 202110

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0981 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10102 HCAHPS Survey (Patients via Hospital Data Collection) Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials Attachment A - 2023_survey-instruments_english_mail.pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials Attachment A - 2023_survey-instruments_english_mail.pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Telephone Script) Attachment B - 2023_HCAHPS Survey - English_telephone.pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Telephone Script) Attachment B - 2023_HCAHPS Survey - English_telephone.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Spanish Attachment C - 2023_HCAHPS Survey Translation - Spanish.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Spanish Attachment C - 2023_HCAHPS Survey Translation - Spanish.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Chinese Attachment D - 2023_HCAHPS Survey Translation - Chinese.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Chinese Attachment D - 2023_HCAHPS Survey Translation - Chinese.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Russian Attachment E - 2023_HCAHPS Survey Translation - Russian.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Russian Attachment E - 2023_HCAHPS Survey Translation - Russian.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Vietnamese Attachment F - 2023_HCAHPS Survey Translation - Vietnamese.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Vietnamese Attachment F - 2023_HCAHPS Survey Translation - Vietnamese.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Portuguese Attachment G - 2023_HCAHPS Survey Translation - Portuguese.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Portuguese Attachment G - 2023_HCAHPS Survey Translation - Portuguese.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - German Attachment H - 2023_HCAHPS Survey Translation - German.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - German Attachment H - 2023_HCAHPS Survey Translation - German.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Tagalog Attachment I - 2023_HCAHPS Survey Translation - Tagalog.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Tagalog Attachment I - 2023_HCAHPS Survey Translation - Tagalog.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Arabic Attachment J - 2023_HCAHPS Survey Translation - Arabic.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Arabic Attachment J - 2023_HCAHPS Survey Translation - Arabic.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HCAHPS Survey (Patients via Hospital Data Collection)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (Mail) and Supporting Materials	Attachment A - 2023_survey-instruments_english_mail.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (Telephone Script)	Attachment B - 2023_HCAHPS Survey - English_telephone.pdf	No		Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Translation - Spanish	Attachment C - 2023_HCAHPS Survey Translation - Spanish.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Translation - Chinese	Attachment D - 2023_HCAHPS Survey Translation - Chinese.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Translation - Russian	Attachment E - 2023_HCAHPS Survey Translation - Russian.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Translation - Vietnamese	Attachment F - 2023_HCAHPS Survey Translation - Vietnamese.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Translation - Portuguese	Attachment G - 2023_HCAHPS Survey Translation - Portuguese.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Translation - German	Attachment H - 2023_HCAHPS Survey Translation - German.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Translation - Tagalog	Attachment I - 2023_HCAHPS Survey Translation - Tagalog.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Translation - Arabic	Attachment J - 2023_HCAHPS Survey Translation - Arabic.pdf	Yes	Yes	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: 4,450	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,450	-150	4,600
Annual IC Time Burden (Hours)	4,450	-150	4,600
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.