Information Collection

HCAHPS Survey (Patients via Hospital Data Collection)

IC 202110 under ICR 202408-0938-037 · OMB 0938-0981.

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 -- 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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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 -- 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 %

table that charts list of burden
	Approved	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

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.