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Nation-wide Customer Satisfaction Surveys
Nation-wide Customer Satisfaction Surveys
OMB: 2900-0712
IC ID: 182342
OMB.report
VA
OMB 2900-0712
ICR 201112-2900-017
IC 182342
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0712 can be found here:
2021-11-08 - Reinstatement with change of a previously approved collection
2018-01-24 - Reinstatement with change of a previously approved collection
Documents and Forms
Document Name
Document Type
Form VA Form 10-1465-3
Nation-wide Customer Satisfaction Surveys
Form and Instruction
VA Form 10-1465-3 SHEP Outpatient Long Form 10-1465-3
VA Form 10-1465-3 update[1].pdf
Form and Instruction
VA Form 10-1465-4 SHEP Outpatient Short Form 10-1465-4
VA Form 10-1465-4 update[1].pdf
Form and Instruction
VA Form 10-1465-2 HCAHPS SHEP Core Short Form 10-1465-2
VA Form 10-1465-2[1].pdf
Form and Instruction
VA Form 10-1465-5 Clinician and Group Survey , Patient Centered Medical Ho
VA Form 10-1465-5, Clinician_Group Survey Pat Cntrd Med Home_short form.pdf
Form and Instruction
VA Form 10-1465-6 Clinician and Group Survey Patient Centered Medical Home
VA Form 10-1465-6, Clinician and Group Survey Pat Centered Med Home_Long form(1).pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Nation-wide Customer Satisfaction Surveys
Agency IC Tracking Number:
2900-0712
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
VA Form 10-1465-3
SHEP Outpatient Long Form 10-1465-3
VA Form 10-1465-3 update[1].pdf
No
Paper Only
Form and Instruction
VA Form 10-1465-4
SHEP Outpatient Short Form 10-1465-4
VA Form 10-1465-4 update[1].pdf
No
Paper Only
Form and Instruction
VA Form 10-1465-2
HCAHPS SHEP Core Short Form 10-1465-2
VA Form 10-1465-2[1].pdf
No
Paper Only
Form and Instruction
VA Form 10-1465-5
Clinician and Group Survey , Patient Centered Medical Home
VA Form 10-1465-5, Clinician_Group Survey Pat Cntrd Med Home_short form.pdf
No
Paper Only
Form and Instruction
VA Form 10-1465-6
Clinician and Group Survey Patient Centered Medical Home
VA Form 10-1465-6, Clinician and Group Survey Pat Centered Med Home_Long form(1).pdf
No
Paper 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:
313,224
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
313,224
0
88,000
-76,020
0
301,244
Annual IC Time Burden (Hours)
94,118
0
23,333
-25,340
0
96,125
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.