Information Collection

In-Center Hemodialysis CAHPS Survey: National Implementation

IC 207671 under ICR 202504-0938-001 · OMB 0938-0926.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0926 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10105 Medicare In-Center Hemodialysis Survey (English) In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Spanish) In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Samoan) In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Simplified Chinese) In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Traditional Chinese) In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Vietnamese) In-Center Hemodialysis CAHPS Survey: National Implementation	Form and Instruction
ICH-CL1-Eng-Nov2024-OMBRevised.docx	Other-Sample Cover Letter (English)
ICH-CL1-Eng-Nov2024-OMBRevised.docx	Other-Sample Cover Letter (English)
ICH-CL2-Eng-Nov2024-OMBRevised.docx	Other-Sample Cover Letter (English)
ICH-CL2-Eng-Nov2024-OMBRevised.docx	Other-Sample Cover Letter (English)
ICH-CL1-Span-Nov2024-OMBRevised.docx	Other-Sample Cover Letter (Spanish
ICH-CL1-Span-Nov2024-OMBRevised.docx	Other-Sample Cover Letter (Spanish
ICH-CL2-Span-Nov2024-OMBRevised.docx	Other-Sample Cover Letter (Spanish
ICH-CL2-Span-Nov2024-OMBRevised.docx	Other-Sample Cover Letter (Spanish
ICH _CL1_Sam_Nov2024_OMBRevised.docx	Other-Other: Sample Cover Letter (Sa
ICH _CL1_Sam_Nov2024_OMBRevised.docx	Other-Other: Sample Cover Letter (Sa
ICH_CL1_SimChin_Nov2024_OMBRevised.docx	Other-Other: Other: Sample Cover Let
ICH_CL1_SimChin_Nov2024_OMBRevised.docx	Other-Other: Other: Sample Cover Let
ICH_CL1_TradChinese_Nov2024_OMBRevised.docx	Other-Other: Sample Cover Letter (Tr
ICH_CL1_TradChinese_Nov2024_OMBRevised.docx	Other-Other: Sample Cover Letter (Tr
ICH-SurveyStandardVietnamese2024OMB-508.pdf.docx	Other-Other: Other: Sample Cover Let
ICH-SurveyStandardVietnamese2024OMB-508.pdf.docx	Other-Other: Other: Sample Cover Let
CMS-10105 Medicare In-Center Hemodialysis Survey (English) ICH-SurveyStandardEnglish2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (English) ICH-SurveyStandardEnglish2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Spanish) ICH-SurveyStandardSpanish2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Spanish) ICH-SurveyStandardSpanish2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Samoan) ICH-SurveyStandardSamoan2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Samoan) ICH-SurveyStandardSamoan2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Simplified Chine ICH-SurveyStandardSimplifiedChinese2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Simplified Chine ICH-SurveyStandardSimplifiedChinese2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Traditional Chin ICH-SurveyStandardTraditionalChinese2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Traditional Chin ICH-SurveyStandardTraditionalChinese2024OMB-508.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Vietnamese) ICH-SurveyStandardVietnamese2024OMB-508.pdf.docx	Form and Instruction
CMS-10105 Medicare In-Center Hemodialysis Survey (Vietnamese) ICH-SurveyStandardVietnamese2024OMB-508.pdf.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

In-Center Hemodialysis CAHPS Survey: National Implementation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Sample Cover Letter (English)		No		Paper Only
Other-Sample Cover Letter (English)		No		Paper Only
Form and Instruction	CMS-10105	Yes	Yes	Fillable Printable
Other-Sample Cover Letter (Spanish		No		Paper Only
Other-Sample Cover Letter (Spanish		No		Paper Only
Form and Instruction	CMS-10105	Yes	Yes	Fillable Printable
Other-Other: Sample Cover Letter (Samoan)		No		Paper Only
Form and Instruction	CMS-10105	Yes	Yes	Fillable Printable
Other-Other: Other: Sample Cover Letter (Simple Chinese		No		Paper Only
Form and Instruction	CMS-10105	Yes	Yes	Fillable Printable
Other-Other: Sample Cover Letter (Traditional Chinese)		No		Paper Only
Form and Instruction	CMS-10105	Yes	Yes	Fillable Printable
Other-Other: Other: Sample Cover Letter (Vietnamese)		No		Paper Only
Form and Instruction	CMS-10105	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: 95,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	190,000	-17,000	207,000
Annual IC Time Burden (Hours)	51,300	-4,590	55,890
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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