VA Form 10-0541 Survey of Veterans' Satisfaction with Income Verificatio

OMB: 2900-0770
Estimated Burden: 6 minutes

DEPARTMENT OF VETERANS AFFAIRS
VETERANS HEALTH ADMINISTRATION

SURVEY OF VETERANS' SATISFACTION WITH THE
INCOME VERIFICATION PROCESS SERVICE

Thank you for your help with this important project. This booklet contains questions
about your experiences with the income verification process administered by the VA's
Health Eligibility Center (HEC).

To assist in determining whether you should proceed with this survey, please read
and answer this question first.

According to our records, the Health Eligibility Center recently verified your income information
to determine your eligibility for VA heath care benefits and mailed you a letter. Do you recall
receiving correspondence from the Health Eligibility Center?
(Mark only one circle below)
Yes (Continue on the next page with the instructions for filling out the survey. Then continue to
Question 1 on Page 1 and complete the survey.)

No (Stop. You do not have to complete the rest of this survey, but please return the survey in the enclosed
postage -paid envelope.)

Again, we thank you for helping the Health Eligibility Center to provide better service
to veterans.

OMB Control Number: 2900-0070
Paperwork Reduction Act Statement: The Paperwork Reduction Act of 1995 (PRA) requires us to
notify you that this information collection is in accordance with the clearance requirements of section
3507 of the PRA. VA may not conduct, sponsor, or require the respondent to respond to this collection
of information unless it displays a valid OMB Control Number. All responses for this collection are
voluntary. Public reporting burden for this collection of information is estimated to average 6 minutes
per response, including the time necessary for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information.
The information collected is intended for the improvement of processes. Failure to furnish the requested
information will have no adverse effect on any VA benefits to which you may be entitled.

Instructions
• Use a pencil or black pen.
• Mark only one answer for each question, unless it tells you to “mark all that apply”.
• Please shade your answer selection completely.
• To maintain privacy, please do not include your name, address, claim number or any
other identifying information.
• When you have completed the survey, place it in the enclosed postage-paid envelope
and put it in the mail.

VA FORM 10-0541
JAN 2012

OMB 2900Estimated Burden: 6 min.

This survey will help the Health Eligibility Center improve it's
Income Verification process.
Letters/Mailings
Q1

We send several letters to Veterans during the Income Verification Process. Please rate the following
statements on a scale of 1 to 5 with 5 being completely agree.
1 (not at all)

2

3

4

5 (completely)

I understood the letters completely
The wording was clear and
understandable
The instructions were easy to understand

Contacts with Staff
Q2

If you contacted the Income Verification Staff, please rate the following statements on a scale of 1 to 5
with 5 being completely agree.
1 (not at all)

2

3

4

5 (completely)

I felt the staff cared about my concerns
I was treated with dignity and respect
The answers provided were clear and
understandable

Q3

If you contacted our office, what was the reason(s)? (mark all that apply)
Did not
understand
the
letters .....

Check
the status
of mail
sent ........

Provide
additional
information...........

Complain
about the
process...

File
Notice of
Disagreement .......

Other,
enter in
Q7
below.......

Income Verification Process
Q4

Please rate your understanding of the Income Verification process.
Completely....

Q5

Mostly ...........

Somewhat.....

Only a little....

Not at all .......

Which areas would you like to see us improve services? (please select the two most important)
The waiver and hardship process
What are valid dependents
What income counts and what does not
What is deductable and how do I find the
correct documents to mail in

Q6

All things considered. please rate your overall satisfaction with the Income Verification process service.
Excellent .......

Q7

Very Good ....

Good.............

Reason for contacting Income Verification. From question 3

VA Form 10-0541
JAN 2012

Fair ...............

Poor ..............

OMB 2900Estimated Burden: 6 min.

Q8

Please enter comments to improve Income Verification process service

VA Form 10-0541
JAN 2012