VA Form 10-0540 Teleretinal Patient Satisfaction Survey

OMB 2900-0770
Estimated Burden: 2 min.

Veterans Health Administration

Teleretinal Imaging
Patient Satisfaction Survey
OMB 2900-0770
VA FORM 10-0540

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 2 minutes. This includes the
time it will take to read instructions, gather the necessary facts and fill out the form. Customer
satisfaction surveys are used to gauge customer perceptions of VA services as well as customer
expectations and desires. The results of this survey will lead to improvement in the quality of
service delivery by helping to shape the direction and focus of specific programs or services.
Completion of this form is voluntary and failure to respond will have no impact on benefits to which
you may be entitled.

OMB 2900-0770
Estimated Burden: 2 min.

VA FORM 10-0540
FEBRUARY 2012