Information Collection

Nation-wide Customer Satisfaction Surveys

IC 182342 under ICR 201306-2900-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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 SHEP_10-1465-3_OutP_Long.pdf	Form and Instruction
VA Form 10-1465-5 SHEP PCMH Short Form 10-1465-5 SHEP_10-1465-5_PCMH_Short.pdf	Form and Instruction
VA Form 10-1465-2 HCAHPS SHEP Core Short Form 10-1465-2 SHEP_10-1465-2_InPat_Short.pdf	Form and Instruction

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	VA Form 10-1465-3	SHEP Outpatient Long Form 10-1465-3	SHEP_10-1465-3_OutP_Long.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-5	SHEP PCMH Short Form 10-1465-5	SHEP_10-1465-5_PCMH_Short.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-2	HCAHPS SHEP Core Short Form 10-1465-2	SHEP_10-1465-2_InPat_Short.pdf	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 399,000

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	Previously Approved
Annual Number of Responses for this IC	399,000	97,756	301,244
Annual IC Time Burden (Hours)	101,750	5,625	96,125
Annual IC Cost Burden (Dollars)	0	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.