Information Collection

HOS Field Test

IC 263064 under ICR 202512-0938-008 · OMB 0938-1464.

Documents and Forms

Document Name Document Type
Form CMS-10861 HOS Field Test Form and Instruction
Form CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questionnaire Version A HOS Field Test Form and Instruction
Form CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questionnaire Version B HOS Field Test Form and Instruction
Form CMS-10861 HOS Field Test Item Differences by Questionnaire HOS Field Test Form and Instruction
CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questio Attachment A. HOS Field Test 2025 Questionnaire (Version A).docx Form and Instruction
CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questio Attachment A. HOS Field Test 2025 Questionnaire (Version A).docx Form and Instruction
CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questio Attachment B. HOS Field Test 2025 Questionnaire (Version B).docx Form and Instruction
CMS-10861 Medicare Health Outcomes Survey (HOS) Field Test Questio Attachment B. HOS Field Test 2025 Questionnaire (Version B).docx Form and Instruction
CMS-10861 HOS Field Test Item Differences by Questionnaire Attachment C. Differences between Version A and B.docx Form and Instruction
CMS-10861 HOS Field Test Item Differences by Questionnaire Attachment C. Differences between Version A and B.docx Form and Instruction
Attachment D. CMS HOS Crosswalk.pdf Crosswalk/Track Change document IC Document
Attachment D. CMS HOS Crosswalk.pdf Crosswalk/Track Change document IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HOS Field Test	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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10861	Medicare Health Outcomes Survey (HOS) Field Test Questionnaire Version A	Attachment A. HOS Field Test 2025 Questionnaire (Version A).docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10861	Medicare Health Outcomes Survey (HOS) Field Test Questionnaire Version B	Attachment B. HOS Field Test 2025 Questionnaire (Version B).docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10861	HOS Field Test Item Differences by Questionnaire	Attachment C. Differences between Version A and B.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Health Plan Management System (HPMS)	FR Citation: 83 FR 6591

Number of Respondents: 136	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,800	0	6,800
Annual IC Time Burden (Hours)	1,700	-567	2,267
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk/Track Change document	Attachment D. CMS HOS Crosswalk.pdf	12/08/2025

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

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