Form 1 Attachment A- Child CAHPS Registration form

The Child HCAHPS Data Submission System
Account Registration
Please provide the following information to register for an account. The information you provide
for registration purposes will be kept confidential. The CAHPS Database will review your
request and will send you an e-mail with the information to access the 2026 Child HCAHPS
Survey Data Submission System.

1/31/202900

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time
required to complete the form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer
Attention: PRA, Paperwork Reduction Project (0935-0243) AHRQ, 5600 Fishers Lane, Rockville, MD 20857.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by
Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information
that could identify you will not be disclosed unless you have consented to that disclosure.