Information Collection

National Implementation

IC 212899 under ICR 202407-0938-002 · OMB 0938-1257.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1257 can be found here:

2025-04-24 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10537 National Implementation	Form and Instruction
CMS-10537 Hospice Experience of Care Survey - CAHPS Hospice Survey_English_.docx	Form and Instruction
CMS-10537 Hospice Experience of Care Survey - CAHPS Hospice Survey_English_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Korean_ CAHPS Hospice Survey_Korean_06242024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Korean_ CAHPS Hospice Survey_Korean_06242024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Polish CAHPS Hospice Survey_Polish 06212024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Polish CAHPS Hospice Survey_Polish 06212024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Portuguese_ CAHPS Hospice Survey_Portuguese_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Portuguese_ CAHPS Hospice Survey_Portuguese_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Russian_ CAHPS Hospice Survey_Russian_06252024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Russian_ CAHPS Hospice Survey_Russian_06252024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Simplified Chinese_ CAHPS Hospice Survey_Simplified Chinese_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Simplified Chinese_ CAHPS Hospice Survey_Simplified Chinese_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Spanish_ CAHPS Hospice Survey_Spanish_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Spanish_ CAHPS Hospice Survey_Spanish_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice_Vietnamese Survey_ CAHPS Hospice_Vietnamese Survey_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice_Vietnamese Survey_ CAHPS Hospice_Vietnamese Survey_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Traditional Chinese CAHPS Hospice Survey_Traditional Chinese_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Traditional Chinese CAHPS Hospice Survey_Traditional Chinese_.docx	Form and Instruction
Revised Survey Tracked with Changes from CAHPS Hospice QAG V10.0.2024_3_21.docx CAHPS Hospice Survey_Track Change version	IC Document
Revised Survey Tracked with Changes from CAHPS Hospice QAG V10.0.2024_3_21.docx CAHPS Hospice Survey_Track Change version	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

National Implementation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 418

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	CMS-10537	Hospice Experience of Care Survey -	CAHPS Hospice Survey_English_.docx	No	Fillable Printable
Form and Instruction	CMS-10537	CAHPS Hospice Survey_Korean_	CAHPS Hospice Survey_Korean_06242024_.docx	No	Fillable Printable
Form and Instruction	CMS-10537	CAHPS Hospice Survey_Polish	CAHPS Hospice Survey_Polish 06212024_.docx	No	Fillable Printable
Form and Instruction	CMS-10537	CAHPS Hospice Survey_Portuguese_	CAHPS Hospice Survey_Portuguese_06202024_.docx	No	Fillable Printable
Form and Instruction	CMS-10537	CAHPS Hospice Survey_Russian_	CAHPS Hospice Survey_Russian_06252024_.docx	No	Fillable Printable
Form and Instruction	CMS-10537	CAHPS Hospice Survey_Simplified Chinese_	CAHPS Hospice Survey_Simplified Chinese_06202024_.docx	No	Fillable Printable
Form and Instruction	CMS-10537	CAHPS Hospice Survey_Spanish_	CAHPS Hospice Survey_Spanish_06202024_.docx	No	Fillable Printable
Form and Instruction	CMS-10537	CAHPS Hospice_Vietnamese Survey_	CAHPS Hospice_Vietnamese Survey_06202024_.docx	No	Fillable Printable
Form and Instruction	CMS-10537	CAHPS Hospice Survey_Traditional Chinese	CAHPS Hospice Survey_Traditional Chinese_.docx	No	Fillable Printable

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: 1,159,420

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	1,159,420	18,725	1,140,695
Annual IC Time Burden (Hours)	168,116	-30,365	198,481
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CAHPS Hospice Survey_Track Change version	Revised Survey Tracked with Changes from CAHPS Hospice QAG V10.0.2024_3_21.docx	07/10/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.