Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medicare Health Outcomes Survey (HOS)
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 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
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:
2,220
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
1,485
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
Documents for IC
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.