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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
HHCAHPS Survey
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10275
Home Health Care CAHPS Survey (English)
Attachment A_ HHCAHPS_Survey_questionnaire_12_29_2022.pdf
No
Fillable Fileable
Form
CMS-10275
Home Health Care CAHPS Survey (Russian)
HHCAHPS_Questionnaire_Russian.pdf
No
Fillable Fileable
Form
CMS-10275
Home Health Care CAHPS Survey (Spanish)
HHCAHPSQuestionnaireSpanish.pdf
No
Fillable Fileable
Form
CMS-10275
Home Health Care CAHPS Survey (Telephone)
HHCAHPS_TelephoneScript_English.docx
No
Fillable Printable
Form
CMS-10275
Home Health Care CAHPS Survey (Telephone/Proxy)
HHCAHPS_TelephoneScriptProxy_English.docx
No
Fillable Printable
Form
CMS-10275
Consent to Share Question #35 (English)
HHCAHPS_Q35_EnglishText.pdf
No
Fillable Fileable
Form
CMS-10275
Consent to Share Question #35 (Chinese)
HHCAHPS_Questionnaire_ChineseSimplified.pdf
No
Fillable Fileable
Form
CMS-10275
Consent to Share Question #35 (Russian)
HHCAHPS_Questionnaire_Russian.pdf
No
Fillable Fileable
Form
CMS-10275
Consent to Share Question #35 (Traditional Chinese)
HHCAHPS_Questionnaire_ChineseTraditional.pdf
No
Fillable Fileable
Form
CMS-10275
Consent to Share Question #35 (Vietnamese)
HHCAHPS_Q35_VietnameseText.pdf
No
Fillable Fileable
Instruction
Attachment D_ P and G Manual-Chapter4_Sampling_12_29_2022.pdf
No
Printable Only
Form
CMS-10275
Home Health Care CAHPS Survey (Armenian)
HHCAHPS_Questionnaire_Armenian.pdf
No
Fillable Fileable
Form
CMS-10275
Home Health Care CAHPS Survey (Chinese Simplified)
HHCAHPS_Questionnaire_ChineseSimplified.pdf
No
Fillable Fileable
Form
CMS-10275
Home Health Care CAHPS Survey (Chinese Traditional)
HHCAHPS_Questionnaire_ChineseTraditional.pdf
No
Fillable Fileable
Form
CMS-10275
Home Health Care CAHPS Survey (Vietnamese)
HHCAHPS_Questionnaire_Vietnamese.pdf
No
Fillable Fileable
Form
CMS-10237
Consent to Share Question #35 (Armenian)
HHCAHPS_Q35_ConsentShareMailTelephone_Armenian.pdf
No
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:
1,043,447
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,043,447
0
0
-142,793
0
1,186,240
Annual IC Time Burden (Hours)
208,689
0
0
-28,559
0
237,248
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Survey Cover Letters (1st and 2nd mailings)
English - Mail Survey Cover Letters.doc
05/31/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.