VA Form 10-0559 Sodium Dichromate Exposure Exam Feedback Survey

Veterans Health Administration
Initial Sodium Dichromate Exposure Exam
Feedback Survey
OMB 2900-0770
Estimated Burden: 2.5 minutes

The Office of Public Health, Veterans Health Administration, is conducting a survey to obtain
feedback on the Sodium Dichromate Exposure Exam. You are listed as being deployed to
Qarmat Ali in 2003, but did not receive an initial sodium dichromate exposure exam per our
records.
Please take a few minutes to answer the survey questions on the following pages to help VHA
respond to your needs. Please mail back the survey to us in the return envelope provided.

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 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 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 10-0559
JAN 2013

Initial Sodium Dichromate Exposure Exam
1. How did you receive notification that the initial Sodium Dichromate exposure exam was available to you? (Select all that apply)
I heard about it from my health care facility
Letter from the VA
Telephone call from DoD or VA
A mass media outlet such as the internet or newspaper
My unit
Other _____________(specify)
I have not heard about this before (please contact your environmental health coordinator at your facility to schedule a sodium
dichromate exposure exam. The rest of this survey does not apply to you at this time)

2. Why did you decide not to receive an initial sodium dichromate exposure exam? (Select all that apply)
I feel fine and do not have any medical concerns
I can’t take time away from work to go get the exam
Family or personal obligations do not allow time to get the exam
I already had a Gulf War Registry exam in the past and thought that covered everything
I already had a Gulf War Registry exam in the past and plan on getting the sodium dichromate exposure exam next time I have to go to
my facility
I could not get an appointment for a long time
I was not at Qarmat Ali Water Treatment Plant
I could not get to the facility because I do not have transportation
The location of the medical evaluation was inconvenient for me
Other _________________ (specify)

3. I had an appointment scheduled but did not go because:
The VA cancelled my appointment
I did not have transportation to my appointment
I decided it was not necessary at this time
I went to VA for another reason and was satisfied with the care received
The appointment time was inconvenient for me
Other _________________ (specify)

4. How do you feel the VA could get more Veterans that were at Qarmat Ali Water Treatment Plant to participate in the sodium dichromate exposure
exam?

5. Additional comments

Thank you for completing the survey!

Thank you for completing the survey!