Information Collection

Nation-wide Customer Satisfaction Surveys

IC 182342 under ICR 201710-2900-010 · OMB 2900-0712.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0712 can be found here:

2021-11-08 - Reinstatement with change of a previously approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-1465-1 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
VA Form 10-1463-9 SHEP_SC Survey_10-1465-9 VA Form 10-1465-9_SHEP_SC_Survey_FY16T04_CG_Non-Visit_Eng_12.22.2015_rev03a.pdf	Form and Instruction
VA Form 10-1465-10 SHEP VA Community Care_10-1465-10 VA Form 10-1465-10_SHEP_CC_Survey_FY17T04_Eng_01.30.2017_rev01.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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	VA Form 10-1465-1	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
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 10-1463-9	SHEP_SC Survey_10-1465-9	VA Form 10-1465-9_SHEP_SC_Survey_FY16T04_CG_Non-Visit_Eng_12.22.2015_rev03a.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-10	SHEP VA Community Care_10-1465-10	VA Form 10-1465-10_SHEP_CC_Survey_FY17T04_Eng_01.30.2017_rev01.pdf	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 794,400

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	794,400	283,400	511,000
Annual IC Time Burden (Hours)	176,640	71,740	104,900
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.