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Agenda
Reg Review
ICR
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
VA Form 10-1465-1
SHEP InPatient Long Form 10-1465-1
SHEP_IP_Long Form 10-1465-1a.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 10-1465-4a.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 10-1465-8a.pdf
No
Paper Only
Form and Instruction
VA Form 10-1465-9
SHEP Specialty Care Survey Form 10-1465-9
SHEP_SC_Survey_FY16T04_CG_Non-Visit_Eng_12.22.2015_rev03a.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:
511,000
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
511,000
0
0
0
0
511,000
Annual IC Time Burden (Hours)
104,900
0
0
0
0
104,900
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.