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View ICR - OIRA Conclusion

OMB Control No: 0938-1464	ICR Reference No: 202512-0938-008
Status: Active	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
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/16/2026
	Date Received in OIRA: 12/08/2025
Terms of Clearance: Prior to the re-submission of the information collection “Medicare Health Outcomes Survey Field Test (CMS-10861)” (0938-1464), the agency will assess its respondent burden. This assessment will be guided by the principles and priorities set forth in the Executive Order 14192 title "Unleashing Prosperity Through Deregulation" (January 21, 2025) https://www.whitehouse.gov/presidential-actions/2025/01/unleashing-prosperity-through-deregulation/. The assessment will inform and be integrated in the agency’s next extension or revision of this information collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2027	36 Months From Approved	03/31/2027
Responses	6,800	0	6,800
Time Burden (Hours)	1,700	0	2,267
Cost Burden (Dollars)	0	0	0

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
HOS Field Test	CMS-10861, CMS-10861, CMS-10861	, ,

ICR Summary of Burden

	Total Approved	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

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