View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	In-Center Hemodialysis CAHPS Survey: Mode	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-10105	Attachment C - Final ICH CAHPS Survey (English and Spanish)	Attachment C - Final ICH CAHPS Survey (English and Spanish).docx		Yes	No	Fillable Printable
Form	CMS-10105	Attachment E - Telephone Script (English and Spanish)	Attachment E - ICH CAHPS Telephone Script (English and Spanish).docx		No	No	Printable Only

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: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 45 %

	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	5,000	0	5,000	0	0	0
Annual IC Time Burden (Hours)	1,350	0	1,350	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D - Cover Letter for Mode Experiment (English and Spanish)	Attachment D - ICH CAHPS Cover Letter for Mode Experiment (English and Spanish).docx	07/05/2013
Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish)	Attachment F - Pre-Notification Letter for Mode Experiment (English and Spanish).docx	07/05/2013

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