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 CMS-10275. Attachment C_Proposed HHCAHPS Survey question CMS-10275. Attachment C_Proposed HHCAHPS Survey questionnaire (All Languages).pdf Form and Instruction
CMS-10275. Attachment D.1_1stEnglishSurveyCoverLetter.docx CMS-10275. Attachment D.1_1stEnglishSurveyCoverLetter IC Document
CMS-10275. Attachment D.2_2ndEnglishSurveyCoverLetter.docx CMS-10275. Attachment D.2_2ndEnglishSurveyCoverLetter IC Document
CMS-10275. Attachment D.4_StandardTelephoneScriptEnglishREDLINE.docx CMS-10275. Attachment D.4_StandardTelephoneScriptEnglishREDLINE IC Document
CMS-10275. Attachment D.3_ProxyTelephoneScriptEnglishREDLINE.docx CMS-10275. Attachment D.3_ProxyTelephoneScriptEnglishREDLINE 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	CMS-10275. Attachment C_Proposed HHCAHPS Survey questionnaire (All Languages)	CMS-10275. Attachment C_Proposed HHCAHPS Survey questionnaire (All Languages).pdf		Yes	No	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
CMS-10275. Attachment D.1_1stEnglishSurveyCoverLetter	CMS-10275. Attachment D.1_1stEnglishSurveyCoverLetter.docx	07/02/2025
CMS-10275. Attachment D.2_2ndEnglishSurveyCoverLetter	CMS-10275. Attachment D.2_2ndEnglishSurveyCoverLetter.docx	07/02/2025
CMS-10275. Attachment D.4_StandardTelephoneScriptEnglishREDLINE	CMS-10275. Attachment D.4_StandardTelephoneScriptEnglishREDLINE.docx	07/02/2025
CMS-10275. Attachment D.3_ProxyTelephoneScriptEnglishREDLINE	CMS-10275. Attachment D.3_ProxyTelephoneScriptEnglishREDLINE.docx	07/02/2025

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