Information Collection

HCAHPS Survey (Patients via Hospital Data Collection)

IC 202110 under ICR 202404-0938-026 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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 -- HCAHPS Survey Instrument - English -508.pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials Attachment A -- HCAHPS Survey Instrument - English -508.pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Telephone Script) Attachment C -- HCAHPS CATI Script - English.pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Telephone Script) Attachment C -- HCAHPS CATI Script - English.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Spanish Attachment B -- HCAHPS Survey Instrument - Spanish - 508.pdf Form and Instruction
CMS-10102 HCAHPS Survey Translation - Spanish Attachment B -- HCAHPS Survey Instrument - Spanish - 508.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 -- HCAHPS Survey Instrument - English -508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Instrument (Telephone Script)	Attachment C -- HCAHPS CATI Script - English.pdf	No		Fillable Fileable
Form and Instruction	CMS-10102	HCAHPS Survey Translation - Spanish	Attachment B -- HCAHPS Survey Instrument - Spanish - 508.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,461	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,461	11	4,450
Annual IC Time Burden (Hours)	4,461	11	4,450
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.