Nation-wide Customer Satisfaction Surveys

Forms and Documents

Document Name	Status
Form VA Form 10-1465-3 Nation-wide Customer Satisfaction Surveys Form and Instruction	Modified
JUSTIFICATION_B_3_JHS.docx Supplementary Document	2011-03-05
JUSTIFICATION_A_(V7)1_JHS.docx Supplementary Document	2011-03-05
JUSTIFICATION_A_(V6)[1].doc Supporting Statement A	2010-06-03
Reminder & Thank You postcard.pdf Supplementary Document	2010-05-11
Ambulatory Care Pre-notification Letter.pdf Supplementary Document	2010-05-11
Ambulatory Care Cover Letter.pdf Supplementary Document	2010-05-11
JUSTIFICATION_B_[2].doc Supporting Statement B	2010-05-11

IC Document Collections

IC ID	Document Title	Status
182342	Nation-wide Customer Satisfaction Surveys Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0712	ICR Reference No: 201001-2900-008
Status: Historical Active	Previous ICR Reference No: 200710-2900-003
Agency/Subagency: VA	Agency Tracking No: 2900-0712
Title: Nation-wide Customer Satisfaction Surveys
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/21/2011
	Date Received in OIRA: 06/10/2010
Terms of Clearance: Approved consistent with revisions submitted by the VA and included in the public docket.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved	03/31/2011
Responses	301,244	0	301,244
Time Burden (Hours)	96,125	0	96,750
Cost Burden (Dollars)	0	0	0

---

Abstract: The overall purpose of the VHA Office of Quality and Performance Survey of Health Experience of Patients (SHEP) Survey Program is to systematically obtain information from patients that can be used to identify problems or complaints that need attention and to improve the quality of health care services delivered to Veterans. Information obtained from the SHEP Program is one component of a larger Network Directors Performance Agreement system in VHA that culminates in the annual Network Performance Report. Results of each of the customer satisfaction surveys are made readily available to VA Central Office (VACO), Veterans Integrated Service Network (VISN), VHA field staff, and stakeholders as part of the Network Performance Report and via the VA Intranet. Data is used to demonstrate that VA is providing timely, high quality health care services to patients and to measure improvement toward the goal of matching or exceeding the non-VA external benchmark performance.

---

Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 39	03/01/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 88	05/07/2010
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Nation-wide Customer Satisfaction Surveys	VA Form 10-1465-4, VA Form 10-1465-3, VA Form 10-1465-2	SHEP Outpatient Long Form 10-1465-3 ,   SHEP Outpatient Short Form 10-1465-4 ,   HCAHPS SHEP Core Short Form 10-1465-2

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	301,244	301,244	0	0	0	0
Annual Time Burden (Hours)	96,125	96,750	0	0	-625	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The Long form 10-1464-1 has been discontinued. VHA identified alternative sources for the information collected from the additional questions on the survey and no longer needs to collect the information via the Inpatient satisfaction survey. Therefore, all patients selected for this survey project will now receive VA Form 10-1465-2, Inpatient short form.

---

Annual Cost to Federal Government: $12,065,619

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/10/2010

---