OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

In-Center Hemodialysis CAHPS Survey: National Implementation

IC 207671 under ICR 202507-0938-021 · OMB 0938-0926.

Documents and Forms
Document Name
Document Type
Other-Sample Cover Letter (English)
Other-Sample Cover Letter (English)
Other-Sample Cover Letter (English)
Other-Sample Cover Letter (English)
Other-Sample Cover Letter (Spanish
Other-Sample Cover Letter (Spanish
Other-Sample Cover Letter (Spanish
Other-Sample Cover Letter (Spanish
Other-Other: Sample Cover Letter (Sa
Other-Other: Sample Cover Letter (Sa
Other-Other: Other: Sample Cover Let
Other-Other: Other: Sample Cover Let
Other-Other: Sample Cover Letter (Tr
Other-Other: Sample Cover Letter (Tr
Other-Other: Other: Sample Cover Let
Other-Other: Other: Sample Cover Let
Other-Sample Cover Letter (Samoan)
Other-Sample Cover Letter (Samoan)
Other-Sample Cover Letter (Simple Ch
Other-Sample Cover Letter (Simple Ch
Other-Sample Cover Letter (Tradition
Other-Sample Cover Letter (Tradition
Other-Other Sample Cover Letter (Vie
Other-Other Sample Cover Letter (Vie
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

In-Center Hemodialysis CAHPS Survey: National Implementation
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Sample Cover Letter (English) ICH-CL1-Eng-Nov2024-OMBRevised.docx No   Paper Only
Other-Sample Cover Letter (English) ICH-CL2-Eng-Nov2024-OMBRevised.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (English) Rev-ICHCAHPS-Survey-Eng-May2025_508.pdf Yes Yes Fillable Printable
Other-Sample Cover Letter (Spanish ICH-CL1-Span-Nov2024-OMBRevised.docx No   Paper Only
Other-Sample Cover Letter (Spanish ICH-CL2-Span-Nov2024-OMBRevised.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Spanish) Rev-ICH-MailSurvey-Spanish_May2025_508.pdf Yes Yes Fillable Printable
Other-Other: Sample Cover Letter (Samoan) ICH _CL1_Sam_Nov2024_OMBRevised.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Samoan) Rev-ICH-MailSurvey-Sam-Apr2025.pdf Yes Yes Fillable Printable
Other-Other: Other: Sample Cover Letter (Simple Chinese ICH_CL2_SimpChin_Nov2024_OMBRevised.pdf No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Simplified Chinese) Rev-ICH-MailSurvey-SimChin-Apr2025.pdf Yes Yes Fillable Printable
Other-Other: Sample Cover Letter (Traditional Chinese) ICH_CL1_TradChinese_Nov2024_OMBRevised.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Traditional Chinese) Rev-ICH-MailSurvey-TradChin-Apr2025.pdf Yes Yes Fillable Printable
Other-Other: Other: Sample Cover Letter (Vietnamese) ICH-SurveyStandardVietnamese2024OMB-508.pdf.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Vietnamese) Rev-ICH-MailSurvey-Viet-Apr2025.pdf Yes Yes Fillable Printable
Other-Sample Cover Letter (Samoan) ICH_CL2_Sam_Nov2024_OMBRevised.pdf No   Paper Only
Other-Sample Cover Letter (Simple Chinese) ICH_CL2_SimpChin_Nov2024_OMBRevised.pdf No   Paper Only
Other-Sample Cover Letter (Traditional Chinese) ICH_CL2_TradChin_Nov2024_OMBRevised.pdf No   Paper Only
Other-Other Sample Cover Letter (Vietnamese) ICH_CL2_Viet_Nov2024_OMBRevised.pdf No   Paper Only

Health Health Care Services

 

103,750 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 207,500 0 17,500 0 0 190,000
Annual IC Time Burden (Hours) 41,500 0 -9,800 0 0 51,300
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk ICHCAHPS-Crosswalk-for-OMB.pdf 07/16/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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