Information Collection

National Implementation

IC 212899 under ICR 202504-0938-007 · OMB 0938-1257.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10537 National Implementation	Form and Instruction
Form CMS-10537 Hospice Experience of Care Survey - National Implementation	Form and Instruction
Form CMS-10537 CAHPS Hospice Survey_Korean_ National Implementation	Form and Instruction
Form CMS-10537 CAHPS Hospice Survey_Polish National Implementation	Form and Instruction
Form CMS-10537 CAHPS Hospice Survey_Portuguese_ National Implementation	Form and Instruction
Form CMS-10537 CAHPS Hospice Survey_Russian_ National Implementation	Form and Instruction
Form CMS-10537 CAHPS Hospice Survey_Simplified Chinese_ National Implementation	Form and Instruction
Form CMS-10537 CAHPS Hospice Survey_Spanish_ National Implementation	Form and Instruction
Form CMS-10537 CAHPS Hospice_Vietnamese Survey_ National Implementation	Form and Instruction
Form CMS-10537 CAHPS Hospice Survey_Traditional Chinese National Implementation	Form and Instruction
CMS-10537 Hospice Experience of Care Survey - Appendix P_CAHPS Hospice QAG V11.0 Mail Materials - English Jan 2025.Feb 12 2025.docx	Form and Instruction
CMS-10537 Hospice Experience of Care Survey - Appendix P_CAHPS Hospice QAG V11.0 Mail Materials - English Jan 2025.Feb 12 2025.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Korean_ CAHPS Hospice Survey_Korean_06242024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Korean_ CAHPS Hospice Survey_Korean_06242024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Polish CAHPS Hospice Survey_Polish 06212024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Polish CAHPS Hospice Survey_Polish 06212024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Portuguese_ CAHPS Hospice Survey_Portuguese_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Portuguese_ CAHPS Hospice Survey_Portuguese_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Russian_ CAHPS Hospice Survey_Russian_06252024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Russian_ CAHPS Hospice Survey_Russian_06252024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Simplified Chinese_ CAHPS Hospice Survey_Simplified Chinese_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Simplified Chinese_ CAHPS Hospice Survey_Simplified Chinese_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Spanish_ CAHPS Hospice Survey_Spanish_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Spanish_ CAHPS Hospice Survey_Spanish_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice_Vietnamese Survey_ CAHPS Hospice_Vietnamese Survey_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice_Vietnamese Survey_ CAHPS Hospice_Vietnamese Survey_06202024_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Traditional Chinese CAHPS Hospice Survey_Traditional Chinese_.docx	Form and Instruction
CMS-10537 CAHPS Hospice Survey_Traditional Chinese CAHPS Hospice Survey_Traditional Chinese_.docx	Form and Instruction
CAHPS Hospice.Crosswalk 2025_2_19.xlsx CAHPS Hospice Crosswalk	IC Document
CAHPS Hospice.Crosswalk 2025_2_19.xlsx CAHPS Hospice Crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

National Implementation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 418

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form and Instruction	CMS-10537	No	Fillable Printable
Form and Instruction	CMS-10537	No	Fillable Printable
Form and Instruction	CMS-10537	No	Fillable Printable
Form and Instruction	CMS-10537	No	Fillable Printable
Form and Instruction	CMS-10537	No	Fillable Printable
Form and Instruction	CMS-10537	No	Fillable Printable
Form and Instruction	CMS-10537	No	Fillable Printable
Form and Instruction	CMS-10537	No	Fillable Printable
Form and Instruction	CMS-10537	No	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: 1,159,420

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	Previously Approved
Annual Number of Responses for this IC	1,159,420	1,159,420
Annual IC Time Burden (Hours)	168,116	168,116
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CAHPS Hospice Crosswalk		04/08/2025

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

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