Information Collection

Nation-wide Customer Satisfaction Surveys

IC 182342 under ICR 200710-2900-003 · OMB 2900-0712.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0712 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-1465-1 Nation-wide Customer Satisfaction Surveys	Form and Instruction
10-1465-1 HCAHPS SHEP Core_Long Form 10-1465-1 HCAHPS SHEP Core_Long form_10-1465-1.doc	Form and Instruction
10-1465-2 HCAHPS SHEP Core_Short Form_10-1465-2 HCAHPS SHEP Core_Short Form_10-1465-2.doc	Form and Instruction
10-1465-3 SHEP Outpatient_Long Form_10-1465-3 SHEP Outpatient_Long form_10-1465-3.doc	Form and Instruction
10-1465-4 SHEP Outpatient_Short Form_10-1465-4 SHEP Outpatient_Short form_10-1465-4.doc	Form and Instruction

IC Title:

Nation-wide Customer Satisfaction Surveys

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?	Electronic Capability
Form and Instruction	10-1465-1	HCAHPS SHEP Core_Long Form 10-1465-1	HCAHPS SHEP Core_Long form_10-1465-1.doc	No	Paper Only
Form and Instruction	10-1465-2	HCAHPS SHEP Core_Short Form_10-1465-2	HCAHPS SHEP Core_Short Form_10-1465-2.doc	No	Paper Only
Form and Instruction	10-1465-3	SHEP Outpatient_Long Form_10-1465-3	SHEP Outpatient_Long form_10-1465-3.doc	No	Paper Only
Form and Instruction	10-1465-4	SHEP Outpatient_Short Form_10-1465-4	SHEP Outpatient_Short form_10-1465-4.doc	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 301,244

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	301,244	301,244
Annual IC Time Burden (Hours)	96,750	96,750
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.