VA Form 10-0497 VA Courtesy Standards - The Golden Rule Approach Veteran

Department of Veterans Affairs OMB 2900-0770
Estimated Burden: 15 min

VA Courtesy Standards -
The Golden Rule Approach Veteran Feedback Form

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 15 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.

Please indicate your level of satisfaction with the courtesy that was provided to you by VA Customer Services personnel, with 1 being the lowest level and 5 being the highest. Please circle one number.

1. At the check-in desk, did the VA employee make eye to eye contact with you and smile?

Unacceptable Acceptable Exceptional

1 2 3 4 5

2. Did the VA employee introduce themselves to you?

Unacceptable Acceptable Exceptional

1 2 3 4 5

3. Did the VA employee call you by name?

Unacceptable Acceptable Exceptional

1 2 3 4 5

4. Did the VA employee ask you if there was anything else you needed?

Unacceptable Acceptable Exceptional

1 2 3 4 5

5. When the initial check-in process was completed, did the VA employee "Thank you"?

Unacceptable Acceptable Exceptional

1 2 3 4 5

6. If a follow-up appointment was made, were you provided a sheet of paper stating appointment times and dates?

Unacceptable Acceptable Exceptional

1 2 3 4 5

7. If you had a question, did the VA employee answer the question or, offer to get you the information that you wanted?

Unacceptable Acceptable Exceptional

1 2 3 4 5

8. Were the VA employees polite to each other?

Unacceptable Acceptable Exceptional

1. 2 3 4 5

At any time, did you feel that any VA employee was rude or did not give you the attention you should have been given? Help us help other Veterans. Understand that we can make no improvements unless we completely understand how and why this occurred. If possible, provide names, dates, and times. Please be very specific with complete details.

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Did any member of the VA staff go out of their way to be especially kind and helpful to you? Please be specific with names and details

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VA Form 10-0497
July 2012