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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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 10-1465-4	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 %

table that charts list of burden
	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

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.