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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
HCAHPS Survey (Patients)
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 and Instruction
CMS-10102
HCAHPS Survey Instrument (Mail) and Supporting Materials
Attachment A - 2023_survey-instruments_english_mail.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10102
HCAHPS Survey Instrument (Telephone Script)
Attachment B - 2023_HCAHPS Survey - English_telephone.pdf
No
Fillable Fileable
Form and Instruction
CMS-10102
HCAHPS Survey Instrument (Mail) - Spanish
Attachment C - 2023_HCAHPS Survey Translation - Spanish.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10102
HCAHPS Survey Instrument (Mail) - Chinese
Attachment D - 2023_HCAHPS Survey Translation - Chinese.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10102
HCAHPS Survey Instrument (Mail) - Russian
Attachment E - 2023_HCAHPS Survey Translation - Russian.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10102
HCAHPS Survey Instrument (Mail) - Vietnamese
Attachment F - 2023_HCAHPS Survey Translation - Vietnamese.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10102
HCAHPS Survey Instrument (Mail) - Portuguese
Attachment G - 2023_HCAHPS Survey Translation - Portuguese.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10102
HCAHPS Survey Instrument (Mail) - German
Attachment H - 2023_HCAHPS Survey Translation - German.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10102
HCAHPS Survey Instrument (Mail) - Tagalog
Attachment I - 2023_HCAHPS Survey Translation - Tagalog.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10102
HCAHPS Survey Instrument (Mail) - Arabic
Attachment J - 2023_HCAHPS Survey Translation - Arabic.pdf
Yes
Yes
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:
2,300,000
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
2,300,000
0
0
-539,017
0
2,839,017
Annual IC Time Burden (Hours)
277,916
0
0
-65,131
0
343,047
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.