CAHPS Hospice Survey CMS-10537)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10537 CAHPS Hospice Survey_Traditional Chinese	Form and Instruction	Modified	Repair queued
Form CMS-10537 CAHPS Hospice_Vietnamese Survey_	Form and Instruction	Modified	Available
Form CMS-10537 CAHPS Hospice Survey_Spanish_	Form and Instruction	Modified	Repair queued
Form CMS-10537 CAHPS Hospice Survey_Simplified Chinese_	Form and Instruction	Modified	Available
Form CMS-10537 CAHPS Hospice Survey_Russian_	Form and Instruction	Modified	Available
Form CMS-10537 CAHPS Hospice Survey_Portuguese_	Form and Instruction	Modified	Repair queued
Form CMS-10537 CAHPS Hospice Survey_Polish	Form and Instruction	Modified	Available
Form CMS-10537 CAHPS Hospice Survey_Korean_	Form and Instruction	Modified	Available
Form CMS-10537 Hospice Experience of Care Survey -	Form and Instruction	Modified	Available
Form CMS-10537 National Implementation	Form and Instruction	Modified	Repair queued
CMS-10537_ Hospice Survey OMB_Statement_A _2025 Non-Sub .docx	Supporting Statement A	Uploaded 2025-04-08	Available
CMS-10537_ Hospice Survey OMB_Statement_A _2025 Non-Sub .docx	Supporting Statement A	Uploaded 2025-04-08	Repair queued
Hospice Survey OMB_Statement_B.docx	Supporting Statement B	Uploaded 2024-07-10	Available
Hospice Survey OMB_Statement_B.docx	Supporting Statement B	Uploaded 2024-07-10	Repair queued
CMS 10537 - Non-Sub Change Request Memo.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-24	Repair queued
CMS 10537 - Non-Sub Change Request Memo.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-24	Repair queued
CAHPS Hospice.Crosswalk 2025_2_19.xlsx	Supplementary Document	Uploaded 2025-04-08	Repair queued
CAHPS Hospice.Crosswalk 2025_2_19.xlsx	Supplementary Document	Uploaded 2025-04-08	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
212899	National Implementation	Form and Instruction	Modified	CAHPS Hospice Survey_Traditional Chinese
212899	National Implementation	Form and Instruction	Modified	CAHPS Hospice_Vietnamese Survey_
212899	National Implementation	Form and Instruction	Modified	CAHPS Hospice Survey_Spanish_
212899	National Implementation	Form and Instruction	Modified	CAHPS Hospice Survey_Simplified Chinese_
212899	National Implementation	Form and Instruction	Modified	CAHPS Hospice Survey_Russian_
212899	National Implementation	Form and Instruction	Modified	CAHPS Hospice Survey_Portuguese_
212899	National Implementation	Form and Instruction	Modified	CAHPS Hospice Survey_Polish
212899	National Implementation	Form and Instruction	Modified	CAHPS Hospice Survey_Korean_
212899	National Implementation	Form and Instruction	Modified	Hospice Experience of Care Survey -
212899	National Implementation	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1257	ICR Reference No: 202504-0938-007
Status: Active	Previous ICR Reference No: 202407-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: CAHPS Hospice Survey CMS-10537)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/30/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/24/2025
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2027	11/30/2027	11/30/2027
Responses	1,159,420	0	1,159,420
Time Burden (Hours)	168,116	0	168,116
Cost Burden (Dollars)	0	0	0

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Abstract: Hospice currently serves approximately 42% of dying patients in the United States. Medicare covers most hospice patients under a benefit created in 1983 to provide palliative care at the end of life. Despite its 30-year history as a Medicare benefit, to date no single survey has been systematically administered by all hospices across the country to assess experiences of hospice care. This submission requests approval for national implementation of the CAHPS® Hospice Survey and as well as approval for a mode experiment to test for mode effects, if any, when the survey is implemented. The CAHPS® Hospice Survey will sample caregivers of patients who died while under hospice care. Survey administration will start between 2 and 3 months after the death of the patient. The sample will be provided by the hospice program. This information will ultimately be used to improve hospice care throughout the country. The mod experiment is intended to determine what mode effects, if any, are found while implementing the survey. Three modes will be tested: mail-only, telephone-only, and mixed-mode (mail with telephone follow up). The mode experiment will occur simultaneously with the first year of National Implementation of the survey, which is also covered as part of this submission.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3004 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 23598	04/04/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 56383	07/09/2024
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
National Implementation	CMS-10537, CMS-10537, CMS-10537, CMS-10537, CMS-10537, CMS-10537, CMS-10537, CMS-10537, CMS-10537	Hospice Experience of Care Survey - ,   CAHPS Hospice Survey_Korean_ ,   CAHPS Hospice Survey_Polish ,   CAHPS Hospice Survey_Portuguese_ ,   CAHPS Hospice Survey_Russian_ ,   CAHPS Hospice Survey_Simplified Chinese_ ,   CAHPS Hospice Survey_Spanish_ ,   CAHPS Hospice_Vietnamese Survey_ ,   CAHPS Hospice Survey_Traditional Chinese

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ICR Summary 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	1,159,420	1,159,420	0	0	0	0
Annual Time Burden (Hours)	168,116	168,116	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The collections total hourly burden has decreased due to the removal of multiple items on the CAHPS Hospice Survey to shorten the document.

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Annual Cost to Federal Government: $2,000,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/24/2025

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