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Outpatient and Ambulatory Surgery Experience of Care Survey
Outpatient and Ambulatory Surgery Experience of Care Survey (CMS-10500)
OMB: 0938-1240
IC ID: 209906
OMB.report
HHS/CMS
OMB 0938-1240
ICR 201312-0938-022
IC 209906
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1240 can be found here:
2024-02-27 - Extension without change of a currently approved collection
2021-07-30 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form CMS-10500
Outpatient and Ambulatory Surgery Experience of Care Survey
Form
Attachment_B_Cover Letter for First Mailing [5-13-2014].docx
Other-Cover Letter
CMS-10500 Outpatient and Ambulatory Surgery Experience of Care Sur
Outpatient and Ambulatory Surgery Experience of Care Survey_Draft_to_OMB_post_60-day_notice_revisions [rev 12-27-13 by OSORA PRA
Form
CMS-1500 Telephone Interview Script for the Outpatient and Ambula
Attachment_C_Introductory Script for Telephone Contact [5-13-2014].docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Outpatient and Ambulatory Surgery Experience of Care Survey
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
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
CMS-10500
Outpatient and Ambulatory Surgery Experience of Care Survey
Outpatient and Ambulatory Surgery Experience of Care Survey_Draft_to_OMB_post_60-day_notice_revisions [rev 12-27-13 by OSORA PRA].docx
Yes
No
Fillable Printable
Other-Cover Letter
Attachment_B_Cover Letter for First Mailing [5-13-2014].docx
No
Paper Only
Form and Instruction
CMS-1500
Telephone Interview Script for the Outpatient and Ambulatory Surgery Experience of Care Survey
Attachment_C_Introductory Script for Telephone Contact [5-13-2014].docx
Yes
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
2,304
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
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
2,304
2,304
0
0
0
0
Annual IC Time Burden (Hours)
384
384
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.