View Information Collection (IC)

View Information Collection (IC)

IC Title:	Mode Experiment	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	Outpatient and Ambulatory Surgery OAS CAHPS Survey	OAS CAHPS_OMB_Attachment_A_OAS CAHPS Survey-04-21-15.docx		No		Fillable Printable
Other-Cover Letter			OAS CAHPS_OMB_Attachment_B_Cover Letter.docx		No		Paper Only
Form and Instruction	CMS-1500	Telephone Interview Script for the Outpatient and Ambulatory Surgery OAS CAHPS Survey	OAS CAHPS_OMB_Attachment_C_CATI Intro Script_rev (2).docx		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: 4,710	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	4,710	0	2,406	0	0	2,304
Annual IC Time Burden (Hours)	612	0	228	0	0	384
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	OAS CAHPS Crosswalk of Changes to Survey-Letter-Intro.xlsx	05/06/2015

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