Nation-wide Customer Satisfaction Surveys (Survey of Healthcare Experiences of Patients (SHEP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-1465-4 Nation-wide Customer Satisfaction Surveys	Form and Instruction	Modified	Available
SENT_VE_Non_Substantial_Change_White Paper 12 28 15 _ Final - 1.4.16.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-06-22	Available
SHEP Memo regarding Revisions 12-2013.docx	Supplementary Document	Uploaded 2013-12-20	Available
MentalHome Veteran Survey.pdf	Supplementary Document	Uploaded 2013-07-16	Available
CAHPS NursingHome Survey.pdf	Supplementary Document	Uploaded 2013-07-16	Available
2900-0712 justification A 06DEC2013.docx	Supporting Statement A	Uploaded 2013-12-18	Available
2900-0712 Justification B 06DEC2013.docx	Supporting Statement B	Uploaded 2013-12-18	Available
Reminder & Thank You postcard.pdf	Supplementary Document	Uploaded 2010-05-11	Available
Ambulatory Care Pre-notification Letter.pdf	Supplementary Document	Uploaded 2010-05-11	Available
Ambulatory Care Cover Letter.pdf	Supplementary Document	Uploaded 2010-05-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
182342	Nation-wide Customer Satisfaction Surveys	Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0712	ICR Reference No: 201605-2900-004
Status: Historical Active	Previous ICR Reference No: 201312-2900-022
Agency/Subagency: VA	Agency Tracking No: 2900-0712
Title: Nation-wide Customer Satisfaction Surveys (Survey of Healthcare Experiences of Patients (SHEP)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/23/2016
	Date Received in OIRA: 06/22/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2017	03/31/2017	03/31/2017
Responses	511,000	0	511,000
Time Burden (Hours)	104,900	0	104,900
Cost Burden (Dollars)	0	0	0

---

Abstract: The overall purpose of the VHA Office of Quality and Performance Survey of Health Experience of Patients (SHEP) Survey Program is to systematically obtain information from patients that can be used to identify problems or complaints that need attention and to improve the quality of health care services delivered to Veterans. Information obtained from the SHEP Program is one component of a larger Network Directors Performance Agreement system in VHA that culminates in the annual Network Performance Report. Results of each of the customer satisfaction surveys are made readily available to VA Central Office (VACO), Veterans Integrated Service Network (VISN), VHA field staff, and stakeholders as part of the Network Performance Report and via the VA Intranet. Data is used to demonstrate that VA is providing timely, high quality health care services to patients and to measure improvement toward the goal of matching or exceeding the non-VA external benchmark performance.

---

Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	12 FR 3456	01/24/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	12 FR 3456	01/24/2014
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Nation-wide Customer Satisfaction Surveys	VA Form 10-1465-2, VA Form 10-1465-1, VA Form 10-1465-3, VA Form 10-1465-7, VA Form 10-1465-4, VA Form 10-1465-5, VA Form 10-1465-6, VA Form 10-1465-8	SHEP OutPatient Short Form 10-1465-4 ,   SHEP Patient Centered Medical Homes (PCMH) Short Form 10-1465-5 ,   SHEP Patient Centered Medical Homes (PCMH) Long Form 10-1465-6 ,   SHEP Home Healthcare CAHPS Long Form 10-1465-7 ,   SHEP In-Center Hemodialysis (ICHemo) Long Form 10-1465-8 ,   SHEP InPatient Long Form 10-1465-1 ,   SHEP InPatient Short Form 10-1465-2 ,   SHEP OutPatient Long Form 10-1465-3

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	511,000	511,000	0	0	0	0
Annual Time Burden (Hours)	104,900	104,900	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $12,065,619

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 06/22/2016

---