VA Form 10-211013 HEC Enrollment Survey

Department of Veterans Affairs
HEC Healthcare Enrollment Survey
OMB 2900-XXXX
VA Form 10-211013

The Paperwork Reduction Act of 1995: 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 follow instructions, gather
the necessary facts and respond to questions asked. Customer satisfaction is 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. Participation in this
survey is voluntary and failure to respond will have no impact on benefits to which you may be
entitled.

Please SHADE your answer selection

OMB 2900-0770
Estimated Burden: 15 min.

Healthcare Enrollment Survey
Considering your experience from the time you filled out the VHA Healthcare Benefits application
form to the time your received your enrollment decision, please answer the following questions
Q1

Why did you choose to enroll for VA Healthcare
benefits? (choose all that apply)

Q4

To use VA as my primary healthcare provider .........
To use VA for treatment of certain conditions and
to coordinate care with my non-VA providers ..........
To satisfy my requirement to have health insurance
coverage under the Affordable Care Act (also
known as ACA or health care reform)......................

Strongly
Agree

Please select your age group
30 or less.................................................................
31 to 40 ...................................................................
41 to 60 ...................................................................
61 to 70 ...................................................................
Greater than 70 .......................................................

Q3

Please select how you applied for VA Health
Care Benefits?
Internet (if so please go to Q4)..............................
In person with VHA staff (if so please skip to Q5) .
By mail (if so please skip to Q6) ...........................

Agree

Neither
Agree nor
Disagree

Disagree

Strongly
Disagree

The website was
easy to navigate
The website
response time was
acceptable
The wording was
clear and
understandable
The instructions
were easy to
understand
The presentation of
the benefits
application form
was logical
I am confident my
personal information
is secure

Primarily to receive prescription drugs from VA .......
To obtain a Veteran Health Identification Card
(VHIC). ....................................................................

Q2

Please answer the following question
concerning your Internet application experience.
(After answering this question please skip to
Q8.)

Q5

Please answer the following questions
concerning your in person application
experience. (After answering this question
please skip to Q8.)

Over the telephone (if so please skip to Q7).........

Strongly
Agree

Assisted by Veterans Service Organization (VSO) .
The staff was
available to assist
me with filling out
the application form
The staff was
knowledgeable
The staff was
courteous
The staff treated me
with dignity and
respect
The location was
convenient for me

VA Form 10-211013
November 2013
Please SHADE your answer selection

Agree

Neither
agree or
disagree

Disagree

Strongly
disagree

OMB 2900-0770
Estimated Burden: 15 min.

Q6

Please answer the following questions
concerning your mail in application experience.
(After answering this question please skip to
Q8.)
Strongly
agree

Agree

Neither
agree nor
disagree

Disagree

From the time you filled out the healthcare
benefits application form, how long did it take to
get your Enrollment Decision?
1 week or less .........................................................
2 weeks ...................................................................

Strongly
disagree

3 weeks ...................................................................
4 weeks ...................................................................

It was easy for me
to obtain a blank
application form
The instructions
were easy to
understand
The wording was
clear and
understandable
I received a timely
response
concerning my
application

Q7

Q9

5 weeks ...................................................................
6 weeks or more ......................................................
Have not received my Enrollment Decision ............

Q10 If you have not received your enrollment
decision, how long has it been since you
applied? (Otherwise go to Q11)
1 week or less .........................................................
2 weeks ...................................................................
3 weeks ...................................................................

Please answer the following questions
concerning your telephone application
experience.
Strongly
Agree

Agree

Neither
agree or
disagree

4 weeks ...................................................................
5 weeks ...................................................................
6 weeks or more ......................................................

Disagree

Strongly
disagree

Q11 How do you learn about VHA benefits? (check
all that apply)

The staff was
available to assist
me with filling out
the application form
The staff was
knowledgeable
The staff was
courteous
The staff treated me
with dignity and
respect

Doctor or HealthCare professional ..........................
Another Veteran ......................................................
Friend or Family member ........................................
VA Staff member .....................................................
Flyer, brochure or newsletter...................................
Veteran Service Organization ..................................
VA Internet...............................................................

Q8

How long did it take to complete the Health care
benefits application form?
Less than 15 minutes ..............................................
Less than 30 minutes ..............................................
Less than 45 minutes ..............................................
One hour or more ....................................................

VA Form 10-211013
November 2013
Please SHADE your answer selection

Letter from the VA ...................................................
Other, please specify

OMB 2900-0770
Estimated Burden: 15 min.

Q12 How would you describe your overall experience
with the VA Healthcare Enrollment process?

Q13 If you were not Highly satisfied with the
Enrollment process, please tell us why.

Highly Satisfied........................................................

The application was not easy to complete...............

Very Satisfied ..........................................................

It took too long to get my enrollment decision .........

Satisfied .................................................................

VA staff were not helpful..........................................
It took to long to get help filling out the application
form .........................................................................

Somewhat Satisfied.................................................
Not Satisfied at all ..................................................

The on line process was confusing .........................
The VSO was not helpful.........................................
I was denied enrollment...........................................
Other reasons

Q14 Please tell us how we can improve the VHA
Enrollment Process.

VA Form 10-211013
November 2013
Please SHADE your answer selection