VA Form 10-10058 Telephone Care Services Patient Satisfaction Survey

OMB 2900-0770
Estimated Burden: 10 minutes

William S. Middleton Memorial Veterans Hospital and Clinics

Telephone Care Services Patient Satisfaction Survey
THE PAPERWORK REDUCTION ACT OF 1995 requires us to notify you that this information collected is in accordance with the
clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average 10
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. No person will be penalized for failing to furnish this information if it
does not display a currently valid OMB control number. This collection of information is intended to fulfill the need identified by the
Department of Veterans Affairs in their call for the development of needed improvements to the current INSERT NAME OF program. Your
obligation to respond to this survey is voluntary and failure to furnish this information will have no effect on any of your benefits.

For each item identified below, please circle the number best fits your level of satisfaction
with Telephone Care Services.

Courtesy
Courtesy of the nurse/clerk to whom you
spoke on the phone

1 very poor

2 poor

3 fair

4 good

5 very good

Promptness
Promptness with which the telephone
was answered

1 very poor

2 poor

3 fair

4 good

5 very good

If a return call was needed, degree to
which a nurse returned your call within
an acceptable amount of time

1 very poor

2 poor

3 fair

4 good

5 very good

Listening
How well nurse listened to your concerns

1 very poor

2 poor

3 fair

4 good

5 very good

Education
Understandability of the nurse’s advice

1 very poor

2 poor

3 fair

4 good

5 very good

Usefulness of the information given by
the clerk

1 very poor

2 poor

3 fair

4 good

5 very good

Other
Adequacy of time spent on phone with nurse

1 very poor

2 poor

3 fair

4 good

5 very good

Degree to which staff identified themselves
to you

1 very poor

2 poor

3 fair

4 good

5 very good

How well your needs were met by using
Telephone Care Services

1 very poor

2 poor

3 fair

4 good

5 very good

Your likelihood of calling the Telephone
Care Services again

1 very poor

2 poor

3 fair

4 good

5 very good

Overall service provided by the Telephone
Care Services

1 very poor

2 poor

3 fair

4 good

5 very good

Comments:

VA Form
MAR 2013

10-10058