OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Health Outcomes Survey (HOS)

IC 203728 under ICR 202501-0938-006 · OMB 0938-0701.

Documents and Forms
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IC Document
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Information Collection (IC) Details

View Information Collection (IC)

Medicare Health Outcomes Survey (HOS)
 
No Modified
 
Voluntary
 
42 CFR 422.152

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10203 Medicare Health Outcomes Survey HOS Questionnaire (English).docx Yes Yes Fillable Printable
Form CMS-10203 Medicare Health Outcomes Survey-Modified (HOS-M) HOS-M 2024 Questionnaire (English).docx Yes Yes Fillable Printable
Form CMS-10203 Medicare Health Outcome Survey (Chinese) HOS Questionnaire (Chinese).docx Yes Yes Fillable Printable
Form CMS-10203 Medicare Health Outcome Survey (Russian) HOS Questionnaire (Russian).docx Yes Yes Fillable Printable
Form CMS-10203 Medicare Health Outcome Survey (Spanish) HOS Questionnaire (Spanish).docx Yes Yes Fillable Printable
Form CMS-10203 Medicare Health Outcomes Survey-Modified (Chinese) HOS-M 2024 Questionnaire (Chinese).docx Yes Yes Fillable Printable
Form CMS-10203 Medicare Health Outcomes Survey-Modified (Russian) HOS-M 2024 Questionnaire (Russian)_10092024.docx Yes Yes Fillable Printable
Form CMS-10203 Medicare Health Outcomes Survey-Modified (Spanish) HOS-M 2024 Questionnaire (Spanish).docx Yes Yes Fillable Printable

Health Health Care Services

 

1,334 0
   
Individuals or Households
 
   34 %

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

Title Document Date Uploaded
Response Rates Attachment D. 20201216_Response Rates_Updated_Clean.docx 01/13/2025
HOS Questionnaire - Track Changes Attachment B. HOS Questionnaire (English) EDITS.pdf 01/17/2025
HOS-M Questionnaire Cover (Chinese) HOS-M Questionnaire Cover (Chinese).pdf 01/17/2025
HOS-M Questionnaire Cover (English).pdf HOS-M Questionnaire Cover (English).pdf 01/17/2025
HOS-M Questionnaire Cover (Russian) HOS-M Questionnaire Cover (Russian).pdf 01/17/2025
HOS-M Questionnaire Cover (Spanish) HOS-M Questionnaire Cover (Spanish).pdf 01/17/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.