HHCAHPS Survey

CAHPS Home Health Care Survey (CMS-10275)

Documents and Forms

Document Name Document Type
Form CMS-10275 HHCAHPS Survey Form and Instruction
CMS-10275 5. Attachment C_Proposed HHCAHPS Survey questionnaire al 5. Attachment C_Proposed HHCAHPS Survey questionnaire all languages (final rule).pdf Form and Instruction
6.CMS-10275. Attachment D.1_1stEnglishSurveyCoverLetter (final rule).pdf 6.CMS-10275. Attachment D.1_1stEnglishSurveyCoverLetter (final rule) IC Document
7. CMS-10275. Attachment D.2_2ndEnglishSurveyCoverLetter_(final rule).pdf 7. CMS-10275. Attachment D.2_2ndEnglishSurveyCoverLetter_(final rule) IC Document
8. CMS-10275. Attachment D.3_ProxyTelephoneScriptEnglish_(final rule).pdf 8. CMS-10275. Attachment D.3_ProxyTelephoneScriptEnglish_(final rule) IC Document
9. CMS-10275. Attachment D.4_StandardTelephoneScriptEnglish_(final rule).pdf 9. CMS-10275. Attachment D.4_StandardTelephoneScriptEnglish_(final rule) IC Document

Information Collection (IC) Details

IC Title:	HHCAHPS Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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-10275	5. Attachment C_Proposed HHCAHPS Survey questionnaire all languages (final rule)	5. Attachment C_Proposed HHCAHPS Survey questionnaire all languages (final rule).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,025,894	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,025,894	-17,553	1,043,447
Annual IC Time Burden (Hours)	153,884	-54,805	208,689
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
6.CMS-10275. Attachment D.1_1stEnglishSurveyCoverLetter (final rule)	6.CMS-10275. Attachment D.1_1stEnglishSurveyCoverLetter (final rule).pdf	12/02/2025
7. CMS-10275. Attachment D.2_2ndEnglishSurveyCoverLetter_(final rule)	7. CMS-10275. Attachment D.2_2ndEnglishSurveyCoverLetter_(final rule).pdf	12/02/2025
8. CMS-10275. Attachment D.3_ProxyTelephoneScriptEnglish_(final rule)	8. CMS-10275. Attachment D.3_ProxyTelephoneScriptEnglish_(final rule).pdf	12/02/2025
9. CMS-10275. Attachment D.4_StandardTelephoneScriptEnglish_(final rule)	9. CMS-10275. Attachment D.4_StandardTelephoneScriptEnglish_(final rule).pdf	12/02/2025

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