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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
National Implementation
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-10500
OAS CAHPS (Mail Survey)
OAS CAHPS Attachment A-Mail Questionnaire.pdf
No
Fillable Fileable
Form and Instruction
CMS-10500
OAS CAHPS (Telephone Script)
OAS CAHPS Attachment B-CATI Questionnaire.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10500
OAS CAHPS (Web Survey Screenshots)
OAS CAHPS Attachment C-Web Questionnaire.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10500
OAS CAHPS - Spanish
Attachment E1 - OAS CAHPS - Spanish Survey.pdf
No
Fillable Fileable
Form and Instruction
CMS-10500
OAS CAHPS - ChineseSimplified
Attachment E2 - OAS CAHPS - ChineseSimplified.pdf
No
Fillable Fileable
Form and Instruction
CMS-10500
OAS CAHPS - ChineseTraditional
Attachment E3 - OAS CAHPS - ChineseTraditional.pdf
No
Fillable Fileable
Form and Instruction
CMS-10500
OAS CAHPS - Korean
Attachment E4 - OAS CAHPS - Korean.pdf
No
Fillable Fileable
Form and Instruction
CMS-10500
OAS CAHPS - Russian
Attachment E5 - OAS CAHPS - Russian.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:
2,524,400
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
2,524,400
0
0
1,534,400
0
990,000
Annual IC Time Burden (Hours)
328,172
0
0
199,472
0
128,700
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Cover Letters
OAS CAHPS Attachment D1-Mail Cover Letters.pdf
02/23/2024
Letter Invitation for Web Survey
OAS CAHPS Attachment D2-Initial Web Survey Invitation Letter.pdf
02/23/2024
Initial Web Survey Invitation Email
OAS CAHPS Attachment D3-Initial Web Survey Invitation Email.pdf
02/23/2024
Follow up Web Survey Invitation Letter
OAS CAHPS Attachment D4-Followup Web Survey Invitation Letter.pdf
02/23/2024
Follow up Web Survey Invitation Email
OAS CAHPS Attachment D5-Followup Web Survey Invitation Email.pdf
02/23/2024
Web with Mail Followup_Questionnaire Cover Letter
OAS CAHPS Attachment D6-Web with Mail Followup_Questionnaire Cover Letter.pdf
02/23/2024
Prenote Letter for Telephone Only
OAS CAHPS Attachment D7-Prenote Letter for Telephone Only.pdf
02/23/2024
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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The .gov means it's official.
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