Information Collection

Medicare Health Outcomes Survey (HOS)

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10203 Medicare Health Outcomes Survey (HOS)	Form
Form CMS-10203 Medicare Health Outcomes Survey Medicare Health Outcomes Survey (HOS)	Form
Form CMS-10203 Medicare Health Outcomes Survey-Modified (HOS-M) Medicare Health Outcomes Survey (HOS)	Form
Form CMS-10203 Medicare Health Outcome Survey (Chinese) Medicare Health Outcomes Survey (HOS)	Form
Form CMS-10203 Medicare Health Outcome Survey (Russian) Medicare Health Outcomes Survey (HOS)	Form
Form CMS-10203 Medicare Health Outcome Survey (Spanish) Medicare Health Outcomes Survey (HOS)	Form
Form CMS-10203 Medicare Health Outcomes Survey-Modified (Chinese) Medicare Health Outcomes Survey (HOS)	Form
Form CMS-10203 Medicare Health Outcomes Survey-Modified (Russian) Medicare Health Outcomes Survey (HOS)	Form
Form CMS-10203 Medicare Health Outcomes Survey-Modified (Spanish) 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 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 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 (Chinese) HOS Questionnaire (Chinese).docx	Form
CMS-10203 Medicare Health Outcome Survey (Russian) HOS Questionnaire (Russian).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 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 (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 (Russian) HOS-M 2024 Questionnaire (Russian)_10092024.docx	Form
CMS-10203 Medicare Health Outcomes Survey-Modified (Spanish) HOS-M Questionnaire Cover (Spanish).pdf	Form
CMS-10203 Medicare Health Outcomes Survey-Modified (Spanish) HOS-M 2024 Questionnaire (Spanish).docx	Form
Attachment D. 20201216_Response Rates_Updated_Clean.docx Response Rates	IC Document
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
Attachment B. HOS Questionnaire (English) EDITS.pdf HOS Questionnaire - Track Changes	IC Document
HOS-M Questionnaire Cover (Chinese).pdf HOS-M Questionnaire Cover (Chinese)	IC Document
HOS-M Questionnaire Cover (English).pdf HOS-M Questionnaire Cover (English).pdf	IC Document
HOS-M Questionnaire Cover (Russian).pdf HOS-M Questionnaire Cover (Russian)	IC Document
HOS-M Questionnaire Cover (Spanish).pdf HOS-M Questionnaire Cover (Spanish)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10203	Yes	Yes	Fillable Printable
Form	CMS-10203	Yes	Yes	Fillable Printable
Form	CMS-10203	Yes	Yes	Fillable Printable
Form	CMS-10203	Yes	Yes	Fillable Printable
Form	CMS-10203	Yes	Yes	Fillable Printable
Form	CMS-10203	Yes	Yes	Fillable Printable
Form	CMS-10203	Yes	Yes	Fillable Printable
Form	CMS-10203	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	Approved	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

table that charts IC Documents
Title	Document	Date Uploaded
Response Rates		01/13/2025
HOS Questionnaire - Track Changes		01/17/2025
HOS-M Questionnaire Cover (Chinese)		01/17/2025
HOS-M Questionnaire Cover (English).pdf		01/17/2025
HOS-M Questionnaire Cover (Russian)		01/17/2025
HOS-M Questionnaire Cover (Spanish)		01/17/2025

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

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