Information Collection

Pilot of the HCAHPS/SHEP Satisfaction Survey Instruction

IC 45605 under ICR 200610-2900-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-21083a( Pilot of the HCAHPS/SHEP Satisfaction Survey Instruction	Form
VA Form 10-21083a( Survey of Healthcare Experiences of Patients Recently Di 2900-New HCAHPS-SHEP VAF 10-21083a.pdf	Form
VA Form 10-21083b( Survey of Healthcare Experiences of Patients Recently Di 2900-New HCAHPS-SHEP VAF 10-21083b.pdf	Form
VA Form 10-21083c( Survey of Healthcare Experiences of Patients Recently Di 2900-New HCAHPS-SHEP VAF 10-21083c.pdf	Form
VA Form 10-21083d( Survey of Healthcare Experiences of Patients Recently Di 2900-New HCAHPS-SHEP VAF 10-21083d.pdf	Form
VA Form 10-21083e( Survey of Healthcare Experiences of Patients Recently Di 2900-New HCAHPS-SHEP VAF 10-21083e.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-21083a(NR)	Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2004	2900-New HCAHPS-SHEP VAF 10-21083a.pdf	Yes	No	Paper Only
Form	VA Form 10-21083b(NR)	Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2004	2900-New HCAHPS-SHEP VAF 10-21083b.pdf	Yes	No	Paper Only
Form	VA Form 10-21083c(NR)	Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2004	2900-New HCAHPS-SHEP VAF 10-21083c.pdf	Yes	No	Paper Only
Form	VA Form 10-21083d(NR)	Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2006	2900-New HCAHPS-SHEP VAF 10-21083d.pdf	Yes	No	Paper Only
Form	VA Form 10-21083e(NR)	Survey of Healthcare Experiences of Patients Recently Discharged Inpatient 2006	2900-New HCAHPS-SHEP VAF 10-21083e.pdf	Yes	No	Paper Only

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,250	7,250
Annual IC Time Burden (Hours)	3,625	3,625
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.