Information Collection

Individuals

IC 216390 under ICR 202602-0938-015 · OMB 0938-1240.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10500 OAS CAHPS (Mail Survey) Individuals	Form and Instruction
Form CMS-10500 OAS CAHPS (Telephone Script) Individuals	Form and Instruction
Form CMS-10500 OAS CAHPS (Web Survey Screenshots) Individuals	Form and Instruction
Form CMS-10500 OAS CAHPS - Spanish Individuals	Form and Instruction
Form CMS-10500 OAS CAHPS Survey Instrument_Telephone_Spanish Individuals	Form and Instruction
Form CMS-10500 OAS CAHPS Survey Instrument_Web_Spanish Individuals	Form and Instruction
CMS-10500 OAS CAHPS (Mail Survey) Attachment A-OAS CAHPS Survey Instrument (Mail).docx	Form and Instruction
CMS-10500 OAS CAHPS (Telephone Script) Attachment B-OAS CAHPS Survey Instrument (Telephone).docx	Form and Instruction
CMS-10500 OAS CAHPS (Web Survey Screenshots) Attachment C-OAS CAHPS Survey Instrument (Web).docx	Form and Instruction
CMS-10500 OAS CAHPS - Spanish Attachment E1-OAS CAHPS Survey Instrument_Mail_Spanish.docx	Form and Instruction
CMS-10500 OAS CAHPS Survey Instrument_Telephone_Spanish Attachment E2-OAS CAHPS Survey Instrument_Telephone_Spanish.docx	Form and Instruction
CMS-10500 OAS CAHPS Survey Instrument_Web_Spanish Attachment E3-OAS CAHPS Survey Instrument_Web_Spanish.docx	Form and Instruction
Attachment D1-OAS CAHPS Mail Cover Letters.docx Cover Letters	IC Document
Attachment D2-OAS CAHPS Web Survey Invitation Letters.docx Letter Invitation for Web Survey	IC Document
Attachment D3-OAS CAHPS Web Survey Invitation Emails.docx Initial Web Survey Invitation Email	IC Document
Attachment D4-OAS CAHPS Web+Mail Follow-up Cover Letter.docx Follow up Web Survey Invitation Letter	IC Document
OAS CAHPS Attachment D5-Followup Web Survey Invitation Email.pdf Follow up Web Survey Invitation Email	IC Document
OAS CAHPS Attachment D6-Web with Mail Followup_Questionnaire Cover Letter.pdf Web with Mail Followup_Questionnaire Cover Letter	IC Document
OAS CAHPS Attachment D7-Prenote Letter for Telephone Only.pdf Prenote Letter for Telephone Only	IC Document
Attachment A-OAS CAHPS Survey Instrument (Mail)_Redline.pdf Track Change - OAS CAHPS Survey Instrument (Mail)	IC Document
Attachment B-OAS CAHPS Survey Instrument (Telephone)_Redline.pdf OAS CAHPS Survey Instrument (Telephone)	IC Document
Attachment C-OAS CAHPS Survey Instrument (Web)_Redline.pdf OAS CAHPS Survey Instrument (Web)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Individuals

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	No		Fillable Fileable
Form and Instruction	CMS-10500	Yes	Yes	Fillable Fileable

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: 2,037,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,037,300	-487,100	2,524,400
Annual IC Time Burden (Hours)	264,849	-63,323	328,172
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letters		02/12/2026
Letter Invitation for Web Survey		02/12/2026
Initial Web Survey Invitation Email		02/12/2026
Follow up Web Survey Invitation Letter		02/12/2026
Follow up Web Survey Invitation Email		02/23/2024
Web with Mail Followup_Questionnaire Cover Letter		02/23/2024
Prenote Letter for Telephone Only		02/23/2024
Track Change - OAS CAHPS Survey Instrument (Mail)		02/19/2026
OAS CAHPS Survey Instrument (Telephone)		02/19/2026
OAS CAHPS Survey Instrument (Web)		02/19/2026

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

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