VA Form 10-0499 Building Better Caregivers Satisfaction Survey

OMB Number 2900-0770
Estimated Burden: 20 minutes

Veterans Health Administration

Building Better Caregivers
Customer 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 20 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 10-0499
DEC 2012

Building Better Caregivers Customer Satisfaction

Thank you for participating in the Building Better Caregivers workshop. We hope that the workshop was helpful to you in your role as a caregiver for 
a family member or friend. To help us improve the workshop experience for others, we would like to ask you a few questions. We appreciate your 
feedback.  
Thank you. 
Building Better Caregivers Team 

*1. How satisfied were you with the workshop?
j Very satisfied
k
l
m
n
j Satisfied
k
l
m
n
j Neutral
k
l
m
n

j Somewhat unsatisfied
k
l
m
n
j Not at all satisfied
k
l
m
n

*2. Overall, how well did your workshop facilitators help you and others stay actively

involved in the workshop?
j Very well
k
l
m
n
j Well
k
l
m
n

j Neutral
k
l
m
n

j Not well
k
l
m
n

j Not very well
k
l
m
n

*3. As a caregiver, do you feel better prepared to care for your family member?
j Much better prepared
k
l
m
n

j Somewhat better prepared
k
l
m
n
j Neutral
k
l
m
n

j Not much better prepared
k
l
m
n
j Not at all
k
l
m
n

*4. What skills did you learn in the workshop, that you plan to continue using?
5
6  

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Building Better Caregivers Customer Satisfaction

*5. What did you like best about the workshop?
5
6  

*6. What suggestions do you have for improving this workshop?
5
6  

*7. How likely would you be to recommend Building Better Caregivers to others?
j Extremely likely
k
l
m
n
j Very likely
k
l
m
n

j Moderately likely
k
l
m
n
j Slightly likely
k
l
m
n

j Not at all likely
k
l
m
n

If not likely, please let us know why. 

*8. Sometimes it is helpful to use participant comments to help others understand the

usefulness of the workshop. Would you be willing to allow us to use your comments in
promotional information?
I give permission for my comments to be used to promote Building Better Caregivers
workshops. I understand that my name will not be used along with those comments.

j Yes
k
l
m
n
j No
k
l
m
n

We appreciate your time and interest in completing this survey. Your feedback will help us improve Building Better Caregivers. 

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