Information Collection Request

Medicare Health Outcomes Survey (HOS) (CMS-10203)

ICR 202501-0938-006 · OMB 0938-0701 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10203 Medicare Health Outcomes Survey-Modified (Spanish) Form Modified Available
Form CMS-10203 Medicare Health Outcomes Survey-Modified (Russian) Form Modified Available
Form CMS-10203 Medicare Health Outcomes Survey-Modified (Chinese) Form Modified Available
Form CMS-10203 Medicare Health Outcome Survey (Spanish) Form Modified Available
Form CMS-10203 Medicare Health Outcome Survey (Russian) Form Modified Available
Form CMS-10203 Medicare Health Outcome Survey (Chinese) Form Modified Available
Form CMS-10203 Medicare Health Outcomes Survey-Modified (HOS-M) Form Modified Available
Form CMS-10203 Medicare Health Outcomes Survey Form Modified Available
Form CMS-10203 Medicare Health Outcomes Survey (HOS) Form Modified Repair queued
draft response to comments_02272025.docx Supplementary Document Uploaded 2025-03-10 Repair queued
UHC Comments - Medicare Health Outcomes Survey 2.13.2025.pdf Public Comments Uploaded 2025-02-13 Repair queued
SNPA PRA HOS February 13, 2025.pdf Public Comments Uploaded 2025-02-12 Repair queued
PC_202501-0938-006_021225_104632_1.pdf Public Comments Uploaded 2025-02-12 Repair queued
CMS-10203 Supporting Statement A_30day_final.docx Supporting Statement A Uploaded 2025-03-10 Repair queued
1. CMS-10203 Supporting Statement A_.docx Supporting Statement A Uploaded 2025-01-14 Repair queued
UnitedHealthcare.pdf Public Comments Uploaded 2024-12-09 Repair queued
Special Needs Plan Alliance.pdf Public Comments Uploaded 2024-12-06 Repair queued
Commonwealth Care Alliance.pdf Public Comments Uploaded 2024-12-09 Repair queued
CMS-10203 Supporting Statement B_.docx Supporting Statement B Uploaded 2025-01-17 Repair queued
CMS-10203 Supporting Statement B.docx Supporting Statement B Uploaded 2021-04-29 Repair queued
Attachment A. Crosswalk of Changes.docx Supplementary Document Uploaded 2025-01-17 Repair queued
Attachment A. Crosswalk of Changes .docx Supplementary Document Uploaded 2025-01-13 Repair queued
CMS Response to Public Comments Received for CMS-10203 updated.docx Supplementary Document Uploaded 2025-03-10 Repair queued
CMS Response to Public Comments Received for CMS-10203.docx Supplementary Document Uploaded 2025-01-13 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
203728 Medicare Health Outcomes Survey (HOS) Form ModifiedMedicare Health Outcomes Survey-Modified (Spanish)
203728 Medicare Health Outcomes Survey (HOS) Form ModifiedMedicare Health Outcomes Survey-Modified (Russian)
203728 Medicare Health Outcomes Survey (HOS) Form ModifiedMedicare Health Outcomes Survey-Modified (Chinese)
203728 Medicare Health Outcomes Survey (HOS) Form ModifiedMedicare Health Outcome Survey (Spanish)
203728 Medicare Health Outcomes Survey (HOS) Form ModifiedMedicare Health Outcome Survey (Russian)
203728 Medicare Health Outcomes Survey (HOS) Form ModifiedMedicare Health Outcome Survey (Chinese)
203728 Medicare Health Outcomes Survey (HOS) Form ModifiedMedicare Health Outcomes Survey-Modified (HOS-M)
203728 Medicare Health Outcomes Survey (HOS) Form ModifiedMedicare Health Outcomes Survey
203728 Medicare Health Outcomes Survey (HOS) Form Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
06/30/2027 36 Months From Approved 07/31/2025
663,150 0 629,280
212,208 0 201,370
0 0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
Medicare Health Outcomes Survey (HOS) CMS-10203, CMS-10203, CMS-10203, CMS-10203, CMS-10203, CMS-10203, CMS-10203, CMS-10203 ,   ,   ,   ,   ,   ,   ,  

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 663,150 629,280 0 33,870 0 0
Annual Time Burden (Hours) 212,208 201,370 0 10,838 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No