Information Collection

Nation-wide Customer Satisfaction Surveys

IC 182342 under ICR 201605-2900-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form VA Form 10-1465-4 Nation-wide Customer Satisfaction Surveys Form and Instruction
VA Form 10-1465-1 SHEP InPatient Long Form 10-1465-1 SHEP_IP_Long Form 10-1465-1b.pdf Form and Instruction
VA Form 10-1465-2 SHEP InPatient Short Form 10-1465-2 SHEP_IP_Survey_FY15T04_Short_Extended_Eng_12.22.2015_rev03a.pdf Form and Instruction
VA Form 10-1465-3 SHEP OutPatient Long Form 10-1465-3 SHEP_OutPatient_Long Form 10-1465-3a.pdf Form and Instruction
VA Form 10-1465-4 SHEP OutPatient Short Form 10-1465-4 SHEP_OutPatient_Short Form 10-1465-4b.pdf Form and Instruction
VA Form 10-1465-5 SHEP Patient Centered Medical Homes (PCMH) Short Form 10 SHEP_PCMH_Survey_FY16T04_Short_Eng_12.22.2015_rev03a.pdf Form and Instruction
VA Form 10-1465-6 SHEP Patient Centered Medical Homes (PCMH) Long Form 10- SHEP_PCMH_Survey_FY16T04_Long_Flu_Eng_12.22.2015_rev03a.pdf Form and Instruction
VA Form 10-1465-7 SHEP Home Healthcare CAHPS Long Form 10-1465-7 SHEP_HHCAHPS Long Form 10-1465-7a.pdf Form and Instruction
VA Form 10-1465-8 SHEP In-Center Hemodialysis (ICHemo) Long Form 10-1465-8 SHEP_ICHemo Long Form 10-1465-8b.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	Available Electronically?	Electronic Capability
Form and Instruction	VA Form 10-1465-4	SHEP OutPatient Short Form 10-1465-4	SHEP_OutPatient_Short Form 10-1465-4b.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-5	SHEP Patient Centered Medical Homes (PCMH) Short Form 10-1465-5	SHEP_PCMH_Survey_FY16T04_Short_Eng_12.22.2015_rev03a.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-6	SHEP Patient Centered Medical Homes (PCMH) Long Form 10-1465-6	SHEP_PCMH_Survey_FY16T04_Long_Flu_Eng_12.22.2015_rev03a.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-7	SHEP Home Healthcare CAHPS Long Form 10-1465-7	SHEP_HHCAHPS Long Form 10-1465-7a.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-8	SHEP In-Center Hemodialysis (ICHemo) Long Form 10-1465-8	SHEP_ICHemo Long Form 10-1465-8b.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-1	SHEP InPatient Long Form 10-1465-1	SHEP_IP_Long Form 10-1465-1b.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-2	SHEP InPatient Short Form 10-1465-2	SHEP_IP_Survey_FY15T04_Short_Extended_Eng_12.22.2015_rev03a.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-3	SHEP OutPatient Long Form 10-1465-3	SHEP_OutPatient_Long Form 10-1465-3a.pdf	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 511,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	511,000	511,000
Annual IC Time Burden (Hours)	104,900	104,900
Annual IC Cost Burden (Dollars)	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.