OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Nation-wide Customer Satisfaction Surveys

IC 182342 under ICR 201605-2900-004 · OMB 2900-0712.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form VA Form 10-1465-4
SHEP OutPatient Short Form 10-1465-4 Nation-wide Customer Satisfaction Surveys		 Form and Instruction
Form VA Form 10-1465-1
SHEP InPatient Long Form 10-1465-1 Nation-wide Customer Satisfaction Surveys		 Form and Instruction
Form VA Form 10-1465-2
SHEP InPatient Short Form 10-1465-2 Nation-wide Customer Satisfaction Surveys		 Form and Instruction
Form VA Form 10-1465-3
SHEP OutPatient Long Form 10-1465-3 Nation-wide Customer Satisfaction Surveys		 Form and Instruction
Form VA Form 10-1465-5
SHEP Patient Centered Medical Homes (PCMH) Short Form 10-1465-5 Nation-wide Customer Satisfaction Surveys		 Form and Instruction
Form VA Form 10-1465-6
SHEP Patient Centered Medical Homes (PCMH) Long Form 10-1465-6 Nation-wide Customer Satisfaction Surveys		 Form and Instruction
Form VA Form 10-1465-7
SHEP Home Healthcare CAHPS Long Form 10-1465-7 Nation-wide Customer Satisfaction Surveys		 Form and Instruction
Form VA Form 10-1465-8
SHEP In-Center Hemodialysis (ICHemo) Long Form 10-1465-8 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)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction VA Form 10-1465-1 No   Paper Only
Form and Instruction VA Form 10-1465-2 No   Paper Only
Form and Instruction VA Form 10-1465-3 No   Paper Only
Form and Instruction VA Form 10-1465-4 No   Paper Only
Form and Instruction VA Form 10-1465-5 No   Paper Only
Form and Instruction VA Form 10-1465-6 No   Paper Only
Form and Instruction VA Form 10-1465-7 No   Paper Only
Form and Instruction VA Form 10-1465-8 No   Paper Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved 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 511,000 0 0 0 0 511,000
Annual IC Time Burden (Hours) 104,900 0 0 0 0 104,900
Annual IC Cost Burden (Dollars) 0 0 0 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.
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