Nation-wide Customer Satisfaction Surveys

Nation-wide Customer Satisfaction Surveys (Survey of Healthcare Experiences of Patients (SHEP)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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 10-1465-1.pdf Form and Instruction
VA Form 10-1465-2 SHEP InPatient Short Form 10-1465-2 SHEP_IP_Short Form 10-1465-2.pdf Form and Instruction
VA Form 10-1465-3 SHEP OutPatient Long Form 10-1465-3 SHEP_OutPatient_Long Form 10-1465-3.pdf Form and Instruction
VA Form 10-1465-4 SHEP OutPatient Short Form 10-1465-4 SHEP_OutPatient_Short Form 10-1465-4.pdf Form and Instruction
VA Form 10-1465-5 SHEP Patient Centered Medical Homes (PCMH) Short Form 10 SHEP_PCMH_Short Form 10-1465-5.pdf Form and Instruction
VA Form 10-1465-6 SHEP Patient Centered Medical Homes (PCMH) Long Form 10- SHEP_PCMH_Long Form 10-1465-6.pdf Form and Instruction
VA Form 10-1465-7 SHEP Home Healthcare CAHPS Long Form 10-1465-7 SHEP_HHCAHPS Long Form 10-1465-7.pdf Form and Instruction
VA Form 10-1465-8 SHEP In-Center Hemodialysis (ICHemo) Long Form 10-1465-8 SHEP_ICHemo Long Form 10-1465-8.pdf Form and Instruction

Information Collection (IC) Details

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:

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 10-1465-1.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-2	SHEP InPatient Short Form 10-1465-2	SHEP_IP_Short Form 10-1465-2.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-3	SHEP OutPatient Long Form 10-1465-3	SHEP_OutPatient_Long Form 10-1465-3.pdf	No	Paper Only
Form and Instruction	VA Form 10-1465-4	SHEP OutPatient Short Form 10-1465-4	SHEP_OutPatient_Short Form 10-1465-4.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_Short Form 10-1465-5.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_Long Form 10-1465-6.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 10-1465-7.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 10-1465-8.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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	511,000	112,000	399,000
Annual IC Time Burden (Hours)	104,900	3,150	101,750
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.