OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

National Implementation of In-Center Hemodialysis CAHPS Survey (CMS-10105)

OMB 0938-0926 · HHS/CMS.

OMB 0938-0926

CMS designed the ICH CAHPS survey and measures to enable dialysis patients to make more informed decisions when choosing a dialysis facility, to aid facilities in their quality improvement efforts, and to help CMS monitor the performance of dialysis facilities. CMS publicly reports clinical quality measures and patient experience of care survey results for kidney dialysis centers on Care Compare on Medicare.gov. Public reporting of ICH CAHPS data is refreshed in April and October, with each refresh including a rolling average of the two most recent survey periods available. Both clinical and patient experience of care quality measures enable patients with end-stage renal disease (ESRD) to make informed decisions when choosing a dialysis facility. The ICH CAHPS survey fulfills a requirement of the ESRD Quality Incentive Program (QIP).

The latest form for National Implementation of In-Center Hemodialysis CAHPS Survey (CMS-10105) expires 2029-02-28 and is listed under ICR 202509-0938-017.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Vietnamese)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Traditional Chinese)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Simplified Chinese)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Samoan)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (Spanish)Form and Instruction
Form CMS-10105 Medicare In-Center Hemodialysis Survey (English)Form and Instruction
CMS-10105_Supporting_Statement_part_B_ICH CAHPS_ 2025 clean.docxSupporting Statement B
CMS-10105_Supporting_Statement_part_A_ ICH CAHPS_2025 revised CLEAN 9.18.25.docxSupporting Statement A
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Form and Instruction
In-Center Hemodialysis CAHPS Survey: National Implementation Other-Sample Cover Letter (English)

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202509-0938-017 Revision of a currently approved collection 2025-11-26
202507-0938-021 Revision of a currently approved collection 2025-07-16
202504-0938-001 Extension without change of a currently approved collection 2025-04-29
202207-0938-007 Extension without change of a currently approved collection 2022-07-18 Approved with change
201908-0938-009 Extension without change of a currently approved collection 2019-11-19 Approved without change
201609-0938-014 Revision of a currently approved collection 2016-09-28 Approved with change
201307-0938-002 Reinstatement with change of a previously approved collection 2013-07-09 Approved without change
200407-0938-004 New collection (Request for a new OMB Control Number) 2004-07-23 Approved with change