View Information Collection (IC)

View Information Collection (IC)

IC Title:	Medicare Health Outcomes Survey (HOS) and Supporting Regulations 42 CFR 422.152	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10203	Medicare Health Outcomes Survey (HOS 3.0)	Attachment_C_HOS_Proposed_Questionnaire.pdf		Yes	Yes	Fillable Printable
Form	CMS-10203	Medicare Health Outcomes Survey-Modified (HOS-M)	Attachment_D_HOSM_Questionnaire.pdf		Yes	Yes	Fillable Printable
Other-Mailing materials			Attachment_E_Mailing_Materials.pdf		No		Paper 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: 2,340	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 34 %

	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	1,737	0	0	-664,383	0	666,120
Annual IC Time Burden (Hours)	244,187	0	0	24,367	0	219,820
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Response Rates	Attachment_B_Response_Rates.pdf	05/20/2014
Crosswalk	Attachment_A_Crosswalk_of_Changes_to_HOS_Proposed_Questionnaire.pdf	05/20/2014

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