Information Collection

HCAHPS Survey (Patients via Hospital Data Collection)

IC 202110 under ICR 202311-0938-009 · OMB 0938-0981.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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:

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-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 %

table that charts list of burden
	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

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.