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 B. HOS Questionnaire (English).pdf		Yes	Yes	Fillable Printable
Form	CMS-10203	Medicare Health Outcomes Survey-Modified (HOS-M)	Attachment C. HOS-M Questionnaire (English).pdf		Yes	Yes	Fillable Printable
Other-Mailing materials			Attachment E. HOS Mailing Materials.pdf		No		Paper Only
Other-Mailing materials			Attachment F. HOS-M 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: 1,485	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	629,280	0	627,795	0	0	1,485
Annual IC Time Burden (Hours)	201,370	0	18,255	0	0	183,115
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Response Rates	Attachment D. Response Rates.pdf	04/29/2021

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