State Burden

Nationwide Consumer Assessment of Healthcare Providers and Systems (DCAHPS) Survey for Adults in Medicaid

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1239 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10493 State Burden Form and Instruction
CMS-10493 Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid) CMSAdultMedicaidCAHPSEnglishCATI_script 112513_clean.docx Form and Instruction
CMS-10493 CAHPS 5.0H Adult Questionnaire (Medicaid) 11_25_2013_CAHPS_Adult_MEDICAID_Mockup.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	State Burden	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10493	Phone Script - CAHPS 5.0H Adult Questionnaire (Medicaid)	CMSAdultMedicaidCAHPSEnglishCATI_script 112513_clean.docx		No	No	Printable Only
Form and Instruction	CMS-10493	CAHPS 5.0H Adult Questionnaire (Medicaid)	11_25_2013_CAHPS_Adult_MEDICAID_Mockup.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	2,040	2,040
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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