Form VA Form 10-0476 VA Form 10-0476 Michael E. DeBakey Patient Satisfaction Survey

OMB 2900-0775
Estimated Burden 10 minutes

Department of Veterans Affairs

Patient Satisfaction Survey

Michael E. DeBakey Home Care Program
The Paperwork Reduction Act of 1995: This information is collect ed in accordance with se ction 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. Customer satisfaction surveys are used to gauge customer perceptions of VA services as
well as customer expectations and desires. The results of this surve y will lead to im provements in the qualit y of service
delivery by helping to shape the direction and f ocus of speci fic programs and services. Disclo sure of information involves
release of statistical data and other non-identifying data for the improvement of services within the VA healthcare system and
associated administrative purposes. Subm ission of this form is voluntary and failure to respond will have no im pact on
benefits to which you may be entitled.

Hello. I am calling from the MEDVAMC Home Care Program. We are conducting a telephone patient
satisfaction survey for the services you recently received from the home care team. We have several
questions and items to be addressed, which should take no more than ten minutes of your time. Your
feedback is needed and is very important to us. Thank you for your help and time.
I want to remind you that all information is strictly private. It will not affect your VA care.
Please indicate your response to the following questions regarding your home care services: (inform
them of rating scale below)
1 =Strongly Disagree

2 =Disagree

3 =Not Certain

4 =Agree

5 =Strongly Agree

N/A = Not Applicable

The home care program was explained to me

1

2

3

4

5

N/A

The information I received was easy to understand

1

2

3

4

5

N/A

The home care staff was polite and respectful

1

2

3

4

5

N/A

Home visits were made as scheduled or canceled
with notice

1

2

3

4

5

N/A

I have trust and confidence in the home care team

1

2

3

4

5

N/A

When I questioned my care, I got answers I
understood

1

2

3

4

5

N/A

My pain was addressed during the nurse’s visit

1

2

3

4

5

N/A

The nurse explained my medication usage to me

1

2

3

4

5

N/A

I know how to contact the home care team

1

2

3

4

5

N/A

The Home Care Staff did everything they could to
control my pain

1

2

3

4

5

N/A

I am able to suggest ways to improve my safety

1

2

3

4

5

N/A

I am satisfied with the overall services/care
provided by the home care team

1

2

3

4

5

N/A

VA Form 10-0476
June 2010

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Comments:

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VA Form 10-0476
June 2010