VA Form 10-0546 Nuerology/Rehabilitation Inpatient Program Satisfaction

OMB 2900-0770
Estimated Burden: 5 minutes

Department of Veterans Affairs

N eurology Rehabilitation Inpatient Program Survey

PRA 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 consent form will average 5 minutes. This includes the time it will take to read information provided and gather the necessary facts to fill out the form. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

1. After orientation did you have unanswered questions? Yes No

2. The following statements refer to the health care service you received while admitted to the Inpatient Rehabilitation Program from nursing care on __/__/___

2A: I am satisfied with my visit.

Strongly agree Agree No Opinion Disagree Strongly disagree

3. Nursing staff response to your calls: How quick they were to help.

Excellent Good Fair Poor Doesn’t Apply

4. How would you rate how you were assisted in daily hygiene/bath activities?

Excellent Good Fair Poor Doesn’t Apply

5. How well did nurses and other staff explain tests, treatments, discharge information and what to expect?

Excellent Good Fair Poor Doesn’t Apply

6. If you had pain, how well was it controlled?

Not at all Sometimes Almost always Completely Did not have pain

7. How would you rate the cleanliness of the hospital building overall?

Excellent Good Fair Poor Doesn’t Apply

8. How would you rate how well doctors, nurses and another other health care professionals explained what to expect and what to do after leaving the hospital?

Excellent Good Fair Poor Doesn’t Apply

9. The physicians, nurses, therapists and social workers were helpful.

Strongly agree Agree No Opinion Disagree Strong disagree

10. How would you rate the overall care services you received while in rehabilitation?

Excellent Good Fair Poor Doesn’t Apply

11. Would you recommend the OKC VAMC Rehabilitation services to other Veterans?

Yes No

VA FORM 10-0546
MAR 2012