HCAHPS Survey (Patients)

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

Documents and Forms

Document Name Document Type
Form CMS-10102 HCAHPS Survey (Patients) 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 Instrument (Mail) - Spanish Attachment B -- HCAHPS Survey Instrument - Spanish - 508.pdf Form and Instruction
CMS-10102 HCAHPS Survey Instrument (Mail) - Spanish Attachment B -- HCAHPS Survey Instrument - Spanish - 508.pdf Form and Instruction
Attachment D -- Crosswalk of HCAHPS Survey to Updated HCAHPS Survey - OMB 0938-0981.pdf Crosswalk - HCAHPS Survey IC Document
Attachment D -- Crosswalk of HCAHPS Survey to Updated HCAHPS Survey - OMB 0938-0981.pdf Crosswalk - HCAHPS Survey IC Document

Information Collection (IC) Details

IC Title:	HCAHPS Survey (Patients)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 Instrument (Mail) - 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: 2,323,090	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,323,090	23,090	2,300,000
Annual IC Time Burden (Hours)	309,745	31,829	277,916
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk - HCAHPS Survey	Attachment D -- Crosswalk of HCAHPS Survey to Updated HCAHPS Survey - OMB 0938-0981.pdf	05/01/2024

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