View Information Collection (IC)

View Information Collection (IC)

Medicare Health Outcomes Survey (HOS)
 
No Modified
 
Voluntary
 
42 CFR 422.152

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 Questionnaire (rev OSORA PRA).pdf Yes Yes Fillable Printable
Form CMS-10203 Medicare Health Outcomes Survey-Modified (HOS-M) Attachment D_HOS-M Questionnaire (rev OSORA PRA).pdf Yes Yes Fillable Printable
Other-Mailing materials Attachment E_Mailing Materials.pdf No   Paper Only

Health Health Care Services

 

2,220 0
   
Individuals or Households
 
   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 1,485 0 0 -252 0 1,737
Annual IC Time Burden (Hours) 183,115 0 0 -61,072 0 244,187
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Response Rates Attachment B_Response Rates.pdf 09/26/2017
Covariates Used in the Case Mix Adjustment of PCS and MCS Scores Attachment_F_CaseMix_Coefficients.pdf 09/26/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.