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OMB Control No: 0938-1464	ICR Reference No: 202512-0938-008
Status: Received in OIRA	Previous ICR Reference No: 202310-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Medicare Health Outcomes Survey Field Test (CMS-10861)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 12/08/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	03/31/2027
Responses	6,800	6,800
Time Burden (Hours)	1,700	2,267
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	6,800	6,800	0
Annual Time Burden (Hours)	1,700	2,267	-567
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: CMS has removed 16 items and added two items from the field test questionnaires that were previously approved. The average time to complete the HOS field test instrument was decreased from 20 to 15 minutes. This change decreased the annual burden by 566.67 hours from 2,266.67 hours to 1,700 hours.

Annual Cost to Federal Government: $800,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov