Pilot of the HCAHPS/SHEP Satisfaction Survey Instruction

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-21083a( Pilot of the HCAHPS/SHEP Satisfaction Survey Instruction	Form	New	Repair queued
2900-New HCAHP-SHEP VAF 10-21083 Justification Part A.doc	Supporting Statement A	Uploaded 2006-10-10	Repair queued
2900-New HCAHP-SHEP VAF 10-21083 Justification Part B.doc	Supporting Statement B	Uploaded 2006-10-10	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45605	Pilot of the HCAHPS/SHEP Satisfaction Survey Instruction	Form	New

ICR Details

OMB Control No:	ICR Reference No: 200610-2900-004
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Pilot of the HCAHPS/SHEP Satisfaction Survey Instruction
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 12/14/2006
	Date Received in OIRA: 10/16/2006
Terms of Clearance: Withdrawn per VA request submitted to OMB 12/14/06. OMB shall waive the 60 day comment period upon resubmission.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: A series of five pilots is proposed to develop the future patient satisfaction survey for hospitalized veterans. Since VA's SHEP (2900-0227) contains additional questions mandated by Congress, we must test the consequences of adopting the Hospital Consumer Assessment of Health Plan Survey or HCAHPS (0938-0981) alone or in combination with the Survey of Healthcare Experiences of Patients (SHEP) as the national standard satisfaction survey for inpatients.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
   US Code: 38 USC Section 527 Name of Law: Evaluation and data collection
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 134	07/13/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 194	10/06/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Pilot of the HCAHPS/SHEP Satisfaction Survey Instruction	VA Form 10-21083d(NR), VA Form 10-21083e(NR), VA Form 10-21083a(NR), VA Form 10-21083c(NR), VA Form 10-21083b(NR)	Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2004 ,   Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2004 ,   Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2004 ,   Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2006 ,   Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2006

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection so all burden hours are considered a program increase.

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Annual Cost to Federal Government: $109,139

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/16/2006

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