Survey of Healthcare Experiences of Patients (SHEP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-1465-6 SHEP PCMH Ambulatory CareLong Form	Form and Instruction	Modified	Repair queued
Form VA Form 10-1465-4 SHEP Ambulatory Care Short Form	Form and Instruction	Modified	Repair queued
Form VA Form10-1465-3 SHEP Ambulatory Care Long Form	Form and Instruction	Modified	Repair queued
Form VA Form 10-1465-1 SHEP Inpatient Long Form	Form and Instruction	Modified	Repair queued
Form VA Form 10-1465-11 SHEP Recent Visit Survey	Form and Instruction	Modified	Repair queued
Form VA Form 10-1465-10 SHEP VA Community Care	Form and Instruction	Modified	Repair queued
Form VA Form 10-1465-9 SHEP Specialty Care Survey	Form and Instruction	Modified	Repair queued
Form VA Form 10-1465-8 SHEP In-Center Hemodialysis (ICHemo) Long Form	Form and Instruction	Modified	Repair queued
Form VA Form 10-1465-7 SHEP Home Healthcare CAHPS Long Form	Form and Instruction	Modified	Repair queued
Form VA Form 10-1465-5 SHEP Patient Centered Medical Homes (PCMH) Short Form	Form and Instruction	Modified	Repair queued
Form VA Form 10-1465-2 SHEP Inpatient Short Form	Form and Instruction	Modified	Available
Form VA Form 10-1465-2 SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	Available
30-day FRN_SHEP Surveys_published 06232021.pdf	Supplementary Document	Uploaded 2021-06-24	Repair queued
60 Day FRN - SHEP Surveys - Published 04062021.pdf	Supplementary Document	Uploaded 2021-06-16	Repair queued
Supporting Statement A_2900-0712_SHEP Surveys_final Oct 2021.docx	Supporting Statement A	Uploaded 2021-11-08	Repair queued
Supporting Statement B_2900-0712_SHEP Surveys_final Oct 2021.docx	Supporting Statement B	Uploaded 2021-11-05	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP PCMH Ambulatory CareLong Form
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP Ambulatory Care Short Form
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP Ambulatory Care Long Form
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP Inpatient Long Form
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP Recent Visit Survey
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP VA Community Care
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP Specialty Care Survey
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP In-Center Hemodialysis (ICHemo) Long Form
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP Home Healthcare CAHPS Long Form
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP Patient Centered Medical Homes (PCMH) Short Form
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified	SHEP Inpatient Short Form
182342	SHEP - Nationwide Customer Satisfaction Surveys	Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0712	ICR Reference No: 202102-2900-017
Status: Historical Inactive	Previous ICR Reference No: 201710-2900-010
Agency/Subagency: VA	Agency Tracking No: 2900-0712
Title: Survey of Healthcare Experiences of Patients (SHEP)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 02/07/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/08/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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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.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 17891	04/06/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 33014	06/23/2021
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
SHEP - Nationwide Customer Satisfaction Surveys	VA Form 10-1465-9, VA Form 10-1465-1, VA Form10-1465-3, VA Form 10-1465-4, VA Form 10-1465-6, VA Form 10-1465-11, VA Form 10-1465-2, VA Form 10-1465-7, VA Form 10-1465-5, VA Form 10-1465-8, VA Form 10-1465-10	SHEP Inpatient Short Form ,   SHEP Patient Centered Medical Homes (PCMH) Short Form ,   SHEP Home Healthcare CAHPS Long Form ,   SHEP In-Center Hemodialysis (ICHemo) Long Form ,   SHEP Specialty Care Survey ,   SHEP VA Community Care ,   SHEP Recent Visit Survey ,   SHEP Inpatient Long Form ,   SHEP Ambulatory Care Long Form ,   SHEP Ambulatory Care Short Form ,   SHEP PCMH Ambulatory CareLong Form

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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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Historical data has enabled the program office to provide more accurate burden numbers for the SHEP surveys.

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Annual Cost to Federal Government: $12,500,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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Common Form ICR:  No

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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: 11/08/2021

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