View Information Collection (IC)

View Information Collection (IC)

HOPDs/ASCs Patient Records
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10500 OAS CAHPS (Mail Survey) OAS CAHPS Attachment A-Mail Questionnaire.pdf No   Fillable Fileable
Form CMS-10500 OAS CAHPS (Telephone Script) OAS CAHPS Attachment B-CATI Questionnaire.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10500 OAS CAHPS (Web Survey Screenshots) OAS CAHPS Attachment C-Web Questionnaire.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

3,300 0
   
Private Sector Businesses or other for-profits
 
   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 3,300 0 1,126 0 0 2,174
Annual IC Time Burden (Hours) 92,400 0 20,269 0 0 72,131
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Cover Letters OAS CAHPS Attachment D1-Mail Cover Letters.pdf 07/26/2021
Letter Invitation for Web Survey OAS CAHPS Attachment D2-Initial Web Survey Invitation Letter.pdf 07/26/2021
E-mail Invitation for Web Survey (1st Contact) OAS CAHPS Attachment D3-Initial Web Survey Invitation Email.pdf 07/26/2021
Followup Web Survey Invitation Letter OAS CAHPS Attachment D4-Followup Web Survey Invitation Letter.pdf 07/26/2021
Follow up Web Survey Invitation Email OAS CAHPS Attachment D5-Followup Web Survey Invitation Email.pdf 07/26/2021
Web with Mail Followup_Questionnaire Cover Letter OAS CAHPS Attachment D6-Web with Mail Followup_Questionnaire Cover Letter.pdf 07/26/2021
Prenote Letter for Telephone Only OAS CAHPS Attachment D7-Prenote Letter for Telephone Only.pdf 07/26/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.