Pilot Of The Hcahps/shep Satisfaction Survey Instruments

REQUEST FOR APPROVAL OF PILOT OF THE HCAHPS/SHEP SATISFACTION SURVEY INSTRUMENTS, VA FORMS OF THE 10-21083(NR) SERIES

Documents and Forms

Document Name Document Type
Form 10-21083a(NR) PILOT OF THE HCAHPS/SHEP SATISFACTION SURVEY INSTRUMENTS Form
10-21083a(NR) HCAHPS Survey 10-21083a (1).pdf Form
10-21083b (NC) HCAHPS survey plus SHEP items not covered in HCAHPS 10-21083b.pdf Form
10-21083c(NR) HCAHPS and full SHEP Inpatient survey 10-21083c(1).pdf Form
10-21083d(NR) Current SHEP Inpatient document in 2 column format 10-21083d.pdf Form
10-21083e(NR) Current SHEP Inpatient document in 1 column format 10-21083e.pdf Form

Information Collection (IC) Details

IC Title:	PILOT OF THE HCAHPS/SHEP SATISFACTION SURVEY INSTRUMENTS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	10-21083a(NR)	HCAHPS Survey	10-21083a (1).pdf	No	Paper Only
Form	10-21083b (NC)	HCAHPS survey plus SHEP items not covered in HCAHPS	10-21083b.pdf	No	Paper Only
Form	10-21083c(NR)	HCAHPS and full SHEP Inpatient survey	10-21083c(1).pdf	No	Paper Only
Form	10-21083d(NR)	Current SHEP Inpatient document in 2 column format	10-21083d.pdf	No	Paper Only
Form	10-21083e(NR)	Current SHEP Inpatient document in 1 column format	10-21083e.pdf	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,250	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
Annual Number of Responses for this IC	7,250	7,250
Annual IC Time Burden (Hours)	3,625	3,625
Annual IC Cost Burden (Dollars)	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.