View Information Collection (IC)
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ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
SHEP - Nationwide 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
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
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
658,920
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
0
-135,480
794,400
0
Annual IC Time Burden (Hours)
137,415
0
0
-39,225
176,640
0
Annual IC Cost Burden (Dollars)
0
0
0
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.
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