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View Information Collection (IC)

Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152
 
No New
 
Voluntary
 
42 CFR 422.152

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10203 Medicare HOS 2013 Questionnaire (English) Attachment_4_HOS_2_5_Questionnaire_English_REVISED.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10203 Medicare HOS-Modified 2013 Questionnaire (English) Attachment_6_HOS_M_Questionnaire_English.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

2,352 0
   
Individuals or Households
 
   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 666,120 0 666,120 0 0 0
Annual IC Time Burden (Hours) 219,820 0 219,820 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Table of Contents TOC_Revised_Package_Attachments_07252012.pdf 08/14/2012
Publications Attachment_2_Publications.pdf 08/14/2012
Mailing Mater Associated with Medicare HOS (English and Spanish) Attachment_5_HOS_Materials_English_and_Spanish.pdf 08/14/2012
Mailing Material Associated with Medicare HOS-Modified (English) Attachment_7_HOS_M_Materials_English.pdf 08/14/2012
Response Rate Table Attachment_3_Response_Rate_Table.pdf 08/14/2012
Crosswalk Attachment_12_CMS_10203_Crosswalk.pdf 08/14/2012
Covariates Used in the Case Mix Adjustments of PCS and MCS Measures Attachment_8_Covariates.pdf 08/14/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.