VA Form 10-0558 Epilepsy Centers of Excellence (ECoE) Patient Satisfacti

OMB Number 2900-0770
Estimated Burden: 10 minutes

Veterans Health Administration

VA Epilepsy Center of Excellence (ECoE)

Outpatient Clinic Patient Satisfaction Survey

Paperwork Reduction Act 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. 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 improvements in the quality of service delivery by helping to shape the
direction and focus of specific programs and services. Submission of this form is voluntary and failure to
respond will have no impact on benefits to which you may be entitled.

VA Form 10-0558
DEC 2012

*1. Please specify location of epilepsy/seizure clinc:
c Albuquerque
d
e
f
g
c Baltimore
d
e
f
g
c Durham
d
e
f
g

c Gainesville
d
e
f
g
c Houston
d
e
f
g

c Los Angeles
d
e
f
g
c Madison
d
e
f
g
c Miami
d
e
f
g

c Minneapolis
d
e
f
g
c Portland
d
e
f
g

c Richmond
d
e
f
g

c San Antonio
d
e
f
g

c San Francisco
d
e
f
g
c Seattle
d
e
f
g
c Tampa
d
e
f
g

c West Haven
d
e
f
g

*2. I am satisfied with the medical care I receive in epilepsy/seizure clinic?
No Opinion

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

*3. I feel my epilepsy/seizure health care provider treated me with compassion and

understanding.
No Opinion

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

*4. I feel my epilepsy/seizure health care provider spent enough time listening to and

addressing my concerns.
No Opinion

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

*5. I feel my epilepsy/seizure health care provider gave me enough information on my

condition and treatment.
No Opinion

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

*6. I was able to get an appointment with the epilepsy/seizure clinic when I needed.
No Opinion

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

*7. The epilepsy center staff were helpful when I phoned for an appointment, medication

refill or questions.
No Opinion

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

*8. I was seen promptly when I arrived at the epilepsy/seizure clinic?
No Opinion

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

*9. Please describe what we could improve in the epilepsy/seizure clinic. Your direct

comments help us improve the medical services we provide to you. Please do not include
any personally indentifiable information in your response.
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VA form 10-0558