In-Center Hemodialysis CAHPS Survey: National Implementation

National Implementation of In-Center Hemodialysis CAHPS Survey (CMS-10105)

OMB: 0938-0926

IC ID: 207671

Documents and Forms
Document Name
Document Type
Other-Sample Cover Letter (English)
Other-Sample Cover Letter (English)
Other-Sample Cover Letter (Spanish
Other-Sample Cover Letter (Spanish
Other-Other: Sample Cover Letter (Sa
Other-Other: Other: Sample Cover Let
Other-Other: Sample Cover Letter (Tr
Other-Other: Other: Sample Cover Let
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

In-Center Hemodialysis CAHPS Survey: National Implementation
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Sample Cover Letter (English) ICH-CL1-Eng-Nov2024-OMBRevised.docx No   Paper Only
Other-Sample Cover Letter (English) ICH-CL2-Eng-Nov2024-OMBRevised.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (English) ICH-SurveyStandardEnglish2024OMB-508.docx Yes Yes Fillable Printable
Other-Sample Cover Letter (Spanish ICH-CL1-Span-Nov2024-OMBRevised.docx No   Paper Only
Other-Sample Cover Letter (Spanish ICH-CL2-Span-Nov2024-OMBRevised.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Spanish) ICH-SurveyStandardSpanish2024OMB-508.docx Yes Yes Fillable Printable
Other-Other: Sample Cover Letter (Samoan) ICH _CL1_Sam_Nov2024_OMBRevised.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Samoan) ICH-SurveyStandardSamoan2024OMB-508.docx Yes Yes Fillable Printable
Other-Other: Other: Sample Cover Letter (Simple Chinese ICH_CL1_SimChin_Nov2024_OMBRevised.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Simplified Chinese) ICH-SurveyStandardSimplifiedChinese2024OMB-508.docx Yes Yes Fillable Printable
Other-Other: Sample Cover Letter (Traditional Chinese) ICH_CL1_TradChinese_Nov2024_OMBRevised.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Traditional Chinese) ICH-SurveyStandardTraditionalChinese2024OMB-508.docx Yes Yes Fillable Printable
Other-Other: Other: Sample Cover Letter (Vietnamese) ICH-SurveyStandardVietnamese2024OMB-508.pdf.docx No   Paper Only
Form and Instruction CMS-10105 Medicare In-Center Hemodialysis Survey (Vietnamese) ICH-SurveyStandardVietnamese2024OMB-508.pdf.docx Yes Yes Fillable Printable

Health Health Care Services

 

95,000 0
   
Individuals or Households
 
   0 %

  Requested 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 190,000 0 0 -17,000 0 207,000
Annual IC Time Burden (Hours) 51,300 0 0 -4,590 0 55,890
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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