Form VA Form 10-0511 VA Form 10-0511 Cooperative Studies Program (CSP) Site Survey

OMB 2900-XXXX
Estimated Burden: 10 minutes

Cooperative Studies Program (CSP)
Site Survey

Respondent Burden Statement: This information is collected in accordance with Section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Disclosure of information involves release of statistical data and other non-identifying data for the improvement of services within the VA healthcare system and associated administrative purposes. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

CSP Site Survey

In an effort to continue to improve customer service, CSP is conducting a survey to find our strengths and weaknesses. Please answer the following questions. All surveys will remain anonymous.

1. What is your role in the CSP study (optional)?

___________________________________

The following questions refer to your experience interacting with your CSPCC or ERIC (for this survey - Center)

2. How often are you in contact with your Center?

A) Multiple times a week B) Once a week C) 1-3 times a month D) less than once a month

3. Which Center is your study coordinated from? (if on multiple studies, circle more than 1 if necessary)

A) Boston ERIC B) Hines CSPCC C) Palo Alto CSPCC

D) Perry Point CSPCC E) Seattle ERIC F) West Haven CSPCC

4. My Center provides me with the materials and information needed to meet the requirements of the study.

1. Does not meet needs B) Needs improvement C) Meets needs

5. Center staff provides me with knowledgeable answers to questions about the study.

N/A---------Strongly Disagree---------Disagree---------Neutral---------Agree---------Strongly Agree

6. Center staff returns my calls/emails in a timely manner.

N/A---------Strongly Disagree---------Disagree---------Neutral---------Agree---------Strongly Agree

7. Center staff is courteous and professional.

N/A---------Strongly Disagree---------Disagree---------Neutral---------Agree---------Strongly Agree

8. The Operations Manual and Forms provided are clear, accurate and easy to follow.

N/A---------Strongly Disagree---------Disagree---------Neutral---------Agree---------Strongly Agree

9. Overall, how would you rate your Center’s customer service?

N/A------------Poor------------Fair------------Good-----------Very Good------------Excellent

10. How would you rate your Center’s service as it relates to meeting planning?

N/A------------Poor------------Fair------------Good-----------Very Good------------Excellent

11. How would you rate your Center’s service as it relates to regulatory support?

N/A------------Poor------------Fair------------Good-----------Very Good------------Excellent

12. How would you rate your Center’s service as it relates to responding to study issues?

N/A------------Poor------------Fair------------Good-----------Very Good------------Excellent

13. How would you rate your Center’s service as it relates to technical support?

N/A------------Poor------------Fair------------Good-----------Very Good------------Excellent

14. Where could your Center be more helpful?

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VA Form 10-0511
January 2011