Medicare Health Outcomes Survey (HOS)

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

Documents and Forms

Document Name Document Type
Form CMS-10203 Medicare Health Outcomes Survey (HOS) Form
CMS-10203 Medicare Health Outcomes Survey (HOS 3.0) Attachment B- HOS Questionnaire (English).docx Form
CMS-10203 Medicare Health Outcomes Survey-Modified (HOS-M) HOS-M 2024 Questionnaire (English).docx Form
CMS-10203 Medicare Health Outcome Survey (Chinese) HOS Questionnaire (Chinese).docx Form
CMS-10203 Medicare Health Outcome Survey (Russian) HOS Questionnaire (Russian).docx Form
CMS-10203 Medicare Health Outcome Survey (Spanish) HOS Questionnaire (Spanish).docx Form
CMS-10203 Medicare Health Outcomes Survey-Modified (Chinese) HOS-M 2024 Questionnaire (Chinese).docx Form
CMS-10203 Medicare Health Outcomes Survey-Modified (Russian) HOS-M 2024 Questionnaire (Russian).docx Form
CMS-10203 Medicare Health Outcomes Survey-Modified (Spanish) HOS-M Questionnaire Cover (Spanish).pdf Form
Attachment D. 20201216_Response Rates_Updated_Clean.docx Response Rates IC Document
Attachment B. HOS Questionnaire (English) EDITS.pdf HOS Questionnaire - Track Changes IC Document

Information Collection (IC) Details

IC Title:	Medicare Health Outcomes Survey (HOS)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10203	Medicare Health Outcomes Survey (HOS 3.0)	Attachment B- 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).docx	Yes	Yes	Fillable Printable
Form	CMS-10203	Medicare Health Outcomes Survey-Modified (Spanish)	HOS-M Questionnaire Cover (Spanish).pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,334	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 34 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	663,150	33,870	629,280
Annual IC Time Burden (Hours)	212,208	10,838	201,370
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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	01/13/2025

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