OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

SHEP - Nationwide Customer Satisfaction Surveys

IC 182342 under ICR 202102-2900-017 · OMB 2900-0712.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form VA Form 10-1465-2
SHEP - Nationwide Customer Satisfaction Surveys		 Form and Instruction
VA Form 10-1465-2 SHEP Inpatient Short Form
SHEP_Discharged Inpatient_Short Form_2021_09_10-1465-2.pdf 		Form and Instruction
VA Form 10-1465-5 SHEP Patient Centered Medical Homes (PCMH) Short Form
SHEP_PCMH_Ambulatory Care_Short Form_2021_09_10-1465-5.pdf 		Form and Instruction
VA Form 10-1465-7 SHEP Home Healthcare CAHPS Long Form
SHEP_Home Health Care Survey_Long Form 10-1465-7.pdf 		Form and Instruction
VA Form 10-1465-8 SHEP In-Center Hemodialysis (ICHemo) Long Form
SHEP_In-Center Hemodialysis_Long Form_2021_09 10-1465-8.pdf 		Form and Instruction
VA Form 10-1465-9 SHEP Specialty Care Survey
SHEP_Specialty Care Survey_2021_09_10-1465-9.pdf 		Form and Instruction
VA Form 10-1465-10 SHEP VA Community Care
SHEP_VA Community Care_2021_09_10-1465-10.pdf 		Form and Instruction
VA Form 10-1465-11 SHEP Recent Visit Survey
SHEP_Recent Visit Survey_10-1465-11.pdf 		Form and Instruction
VA Form 10-1465-1 SHEP Inpatient Long Form
SHEP_Discharged Inpatient_Long Form 10-1465-1.pdf 		Form and Instruction
VA Form10-1465-3 SHEP Ambulatory Care Long Form
SHEP_Ambulatory Care_Long Form 10-1465-3.pdf 		Form and Instruction
VA Form 10-1465-4 SHEP Ambulatory Care Short Form
SHEP_Ambulatory Care_Short Form 10-1465-4.pdf 		Form and Instruction
VA Form 10-1465-6 SHEP PCMH Ambulatory CareLong Form
SHEP_PCMH_Ambulatory Care_Long Form 10-1465-6.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 10-1465-2 SHEP Inpatient Short Form SHEP_Discharged Inpatient_Short Form_2021_09_10-1465-2.pdf No   Paper Only
Form and Instruction VA Form 10-1465-5 SHEP Patient Centered Medical Homes (PCMH) Short Form SHEP_PCMH_Ambulatory Care_Short Form_2021_09_10-1465-5.pdf Yes Yes Fillable Fileable
Form and Instruction VA Form 10-1465-7 SHEP Home Healthcare CAHPS Long Form SHEP_Home Health Care Survey_Long Form 10-1465-7.pdf Yes Yes Fillable Fileable
Form and Instruction VA Form 10-1465-8 SHEP In-Center Hemodialysis (ICHemo) Long Form SHEP_In-Center Hemodialysis_Long Form_2021_09 10-1465-8.pdf Yes Yes Fillable Fileable
Form and Instruction VA Form 10-1465-9 SHEP Specialty Care Survey SHEP_Specialty Care Survey_2021_09_10-1465-9.pdf Yes Yes Fillable Fileable
Form and Instruction VA Form 10-1465-10 SHEP VA Community Care SHEP_VA Community Care_2021_09_10-1465-10.pdf Yes Yes Fillable Fileable
Form and Instruction VA Form 10-1465-11 SHEP Recent Visit Survey SHEP_Recent Visit Survey_10-1465-11.pdf Yes Yes Fillable Fileable
Form and Instruction VA Form 10-1465-1 SHEP Inpatient Long Form SHEP_Discharged Inpatient_Long Form 10-1465-1.pdf No   Paper Only
Form and Instruction VA Form10-1465-3 SHEP Ambulatory Care Long Form SHEP_Ambulatory Care_Long Form 10-1465-3.pdf No   Paper Only
Form and Instruction VA Form 10-1465-4 SHEP Ambulatory Care Short Form SHEP_Ambulatory Care_Short Form 10-1465-4.pdf No   Paper Only
Form and Instruction VA Form 10-1465-6 SHEP PCMH Ambulatory CareLong Form SHEP_PCMH_Ambulatory Care_Long Form 10-1465-6.pdf No   Paper Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested 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 658,920 0 -135,480 0 794,400 0
Annual IC Time Burden (Hours) 137,415 0 -39,225 0 176,640 0
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.