Form 10-211009 National Patient Centered Community Care Veterans Survey

Department of Veterans Affairs

National Patient Centered Community Care
Veterans Survey Questionnaire
OMB 2900-0770
VA FORM 10-211009

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this
collection of information is estimated to average 15 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. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any
penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
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.

National Patient Centered Community Care Veterans Survey Questions

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Question
Please enter the Unique Identification Code that was provided in your survey request letter. (This
number is 7-9 characters long).
 (text box)
Did your VA provider and/or staff explain your appointment would be scheduled with a
community provider?
 Yes
 No

How satisfied are you with the coordination between VA and NAME OF CONTRACTOR in this
instance of your care?
 Highly Satisfied
 Satisfied
 Neither Satisfied nor Dissatisfied
 Dissatisfied
 Highly Dissatisfied
How many days did you wait until you were contacted to schedule an appointment with the
NAME OF CONTRACTOR provider?
 1 to 5 days
 6 to 14 days
 15 to 21 days
 More than 21 days (more than 3 weeks)
How satisfied are you with the scheduling process to receive an appointment with the NAME OF
CONTRACTOR provider?
 Highly Satisfied
 Satisfied
 Neither Satisfied nor Dissatisfied
 Dissatisfied
 Highly Dissatisfied
How many days did you have to wait between making the appointment and actually seeing the
NAME OF CONTRACTOR provider?
 1 to 7 days
 8 to 14 days
 15 to 21 days
 21 to 30 days
 31 to 61 days (1 to 2 months)
 More than 61 days (more than 2 months)
How satisfied are you with the length of time you waited to get an appointment with the NAME
OF CONTRACTOR provider?

VA Form 10-211009
SEPT 2013

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Question
 Highly Satisfied
 Satisfied
 Neither Satisfied nor Dissatisfied
 Dissatisfied
 Highly Dissatisfied
How long did it take you to travel to the facility where you had your visit?
 Less than 10 minutes
 10 to 30 minutes
 30 to 60 minutes
 60 to 120 minutes (1 to 2 hours)
 120 to 240 minutes (2 to 4 hours)
 More than 240 minutes (more than 4 hours)
How satisfied are you with the convenience of the location?
 Highly Satisfied
 Satisfied
 Neither Satisfied nor Dissatisfied
 Dissatisfied
 Highly Dissatisfied
How satisfied are you with your overall experience at the Non-VA facility?
 Highly Satisfied
 Satisfied
 Neither Satisfied nor Dissatisfied
 Dissatisfied
 Highly Dissatisfied
Was personal information about you treated in a confidential manner?
 Yes, always
 Yes, sometimes
 No
How satisfied are you with the clinical staff?
 Highly Satisfied
 Satisfied
 Neither Satisfied nor Dissatisfied
 Dissatisfied
 Highly Dissatisfied
Did the provider you saw seem to know the important information about your medical history?
 Yes
 No
Overall, how satisfied are you with the care you received during your NAME OF CONTRACTOR
appointment?

VA Form 10-211009
SEPT 2013

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Question
 Highly Satisfied
 Satisfied
 Neither Satisfied nor Dissatisfied
 Dissatisfied
 Highly Dissatisfied
After your NAME OF CONTRACTOR appointment, did you have a question or complaint that
required assistance?
 YesQ14
 NoQ15
How satisfied are you with the ability to obtain answers to questions or complaints regarding your
NAME OF CONTRACTOR appointment?
 Highly Satisfied
 Satisfied
 Neither Satisfied nor Dissatisfied
 Dissatisfied
 Highly Dissatisfied
Is there anything that you would like to share about how the care could have been improved?
 No
 Yes (please specify) (large text box)

VA Form 10-211009
SEPT 2013

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