Information Collection

Mode Experiment: ICH CAHPS Survey for ICH and Home Dialysis Survey

IC 283621 under ICR 202611-0938-008 · OMB 0938-0926.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10105 Medicare In-Center and Home Dialysis Survey (English) Mode Experiment: ICH CAHPS Survey for ICH and Home Dialysis Survey	Form and Instruction
Form CMS-10105 Medicare In-Center and Home Dialysis Survey (Spanish) Mode Experiment: ICH CAHPS Survey for ICH and Home Dialysis Survey	Form and Instruction
CMS-10105 Medicare In-Center and Home Dialysis Survey (English) Combined-ICH-and-Home-Survey-RevOct2026.pdf	Form and Instruction
CMS-10105 Medicare In-Center and Home Dialysis Survey (Spanish) Combined-ICH-Home-Survey-Spanish.pdf	Form and Instruction
ICH-CAHPS-ME-CoverLetter1-MailandMail-Phone.pdf CoverLetter1- Mail and Mail-Phone	IC Document
ICH-CAHPS-ME-CoverLetter1-Web-Mail-Phone.pdf CoverLetter1-Web-Mail-Phone	IC Document
ICH-CAHPS-ME-CoverLetter2-Mail.pdf CoverLetter2-Mail	IC Document
ICH-CAHPS-ME-PrenoteLetter-All-Modes.pdf Prenote Letter-All-Modes	IC Document
ICH-CAHPS-ME-Web-Email-Invite-Web-Mail-Phone.pdf Web-Email-Invite-Web-Mail-Phone	IC Document
ICH-CAHPS-ME-Web-Email-Reminder-Web-Mail-Phone.pdf Web-Email-Reminder-Web-Mail-Phone	IC Document
ICH-CAHPS-ME-Web-Invite-by-Mail-Web-Mail-Phone.pdf Web-Invite-by-Mail-Web-Mail-Phone	IC Document
ICHCAHPS-ME-CoverLetter1-Mail-and-Mail-Phone-Spanish.pdf CoverLetter1-Mail-and-Mail-Phone-Spanish	IC Document
ICHCAHPS-ME-CoverLetter1-Web-Mail-Phone-Spanish.pdf CoverLetter1-Web-Mail-Phone-Spanish	IC Document
ICHCAHPS-ME-CoverLetter2-Mail-Spanish.pdf CoverLetter2-Mail-Spanish	IC Document
ICHCAHPS-ME-PrenoteLetter-All-modes-Spanish.pdf Prenote Letter-All-modes-Spanish	IC Document
ICHCAHPS-ME-Web-Email-Invite-Web-Mail-Phone-Spanish.pdf Web-Email-Invite-Web-Mail-Phone-Spanish	IC Document
ICHCAHPS-ME-Web-Email-Reminder-Web-Mail-Phone-Spanish.pdf Web-Email-Reminder-Web-Mail-Phone-Spanish	IC Document
ICHCAHPS-ME-Web-Invite-by-Mail-Web-Mail-Phone-Spanish.pdf Web-Invite-by-Mail-Web-Mail-Phone-Spanish	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Mode Experiment: ICH CAHPS Survey for ICH and Home Dialysis Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10105				Yes	Yes	Fillable Printable
Form and Instruction	CMS-10105				Yes	Yes	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: 4,270

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
Annual Number of Responses for this IC	4,270	4,270
Annual IC Time Burden (Hours)	769	769
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CoverLetter1- Mail and Mail-Phone		11/06/2026
CoverLetter1-Web-Mail-Phone		11/06/2026
CoverLetter2-Mail		11/06/2026
Prenote Letter-All-Modes		11/06/2026
Web-Email-Invite-Web-Mail-Phone		11/06/2026
Web-Email-Reminder-Web-Mail-Phone		11/06/2026
Web-Invite-by-Mail-Web-Mail-Phone		11/06/2026
CoverLetter1-Mail-and-Mail-Phone-Spanish		11/06/2026
CoverLetter1-Web-Mail-Phone-Spanish		11/06/2026
CoverLetter2-Mail-Spanish		11/06/2026
Prenote Letter-All-modes-Spanish		11/06/2026
Web-Email-Invite-Web-Mail-Phone-Spanish		11/06/2026
Web-Email-Reminder-Web-Mail-Phone-Spanish		11/06/2026
Web-Invite-by-Mail-Web-Mail-Phone-Spanish		11/06/2026

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

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