VA Form 10-211013 Non-VA-Purchased Care Veteran Survey

OMB Number: 2900-0770
Estimated Burden: 7 minutes

Department of Veterans Affairs

National Non-VA Medical Care (NVC) Veteran Survey
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 7 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 expectation 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.

Thank you for taking the time to complete the Non-VA Medical Care Veteran Satisfaction Survey. Non-VA
Medical Care is health care for which Veterans are referred by their VA provider and the VA authorizes the
care to be provided in the community. This online survey is estimated to take less than 7 minutes to
complete. Your responses are completely private. This survey specifically pertains to your Non-VA Medical
Care appointment referenced on your survey request letter.
For each question, please click and add a check in the box that best matches your experience with your
Non-VA Medical Care. Please use the "Next" and "Previous" buttons, and not your browser's buttons, to
navigate.

*1. Please enter the Unique Identification Code that was provided in your survey request letter.

Page 1
VA Form
OCT 2013

10-211013

OMB Number: 2900-0770
Estimated Burden: 7 minutes

Process of Scheduling your Appointment with the Non-VA Medical Care Provider
The following questions pertain to the Non-VA Medical Care appointment scheduling process. Please think about the
appointment process and conversations you may have had.
2. Did a member of the VA staff work with you to schedule your Non-VA Medical Care appointment?
� Yes Q3
� No Q4
� I don't recall Q4
3. How satisfied were you with your level of knowledge regarding what to expect for your appointment with a NonVA Medical Care provider after speaking with VA staff?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
4. How satisfied were you with your ability to see the Non-VA Medical Care provider of your choice?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
� N/A
5. How satisfied were you with the level in which your personal preferences were taken into consideration when
scheduling your Non-VA Medical Care appointment?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
� N/A
6. Overall, how satisfied were you with the scheduling process of your Non-VA Medical Care appointment?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied

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VA Form
OCT 2013

10-211013

OMB Number: 2900-0770
Estimated Burden: 7 minutes

Perception of your Non-VA Medical Care Experience
The next set of questions explores several topics of your health care experience.
Before your visit with the Non-VA Medical Care provider:
7. How satisfied were you with the length of time you waited to get an appointment with the Non-VA Medical Care
provider?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
8. How long did it take you to travel to the Non-VA Medical Care 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)
9. How satisfied were you with the convenience of the Non-VA Medical Care location?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
During your visit with the Non-VA Medical Care provider:
10. How satisfied were you with your Non-VA Medical Care appointment facilities?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
11. How satisfied were you with the Non-VA Medical Care staff?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
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VA Form
OCT 2013

10-211013

OMB Number: 2900-0770
Estimated Burden: 7 minutes

12. How satisfied were you with the level to which the Non-VA Medical Care provider demonstrated understanding
regarding your medical background?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
After your visit with the Non-VA Medical Care provider:
13. Did you have a question and/or complaint that required VA Staff assistance?
� Yes Q14
� No Q15
14. How satisfied were you with the availability of VA Staff to address question(s) and/or concern(s) regarding your
Non-VA Medical Care appointment?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
� N/A
15. Did a VA staff member contact you for follow-up regarding your Non-VA Medical Care appointment?
� Yes
� No
16. How satisfied were you with post-visit information provided by VA staff after your Non-VA Medical Care
appointment?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied

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VA Form
OCT 2013

10-211013

OMB Number: 2900-0770
Estimated Burden: 7 minutes

General Questions Regarding your Non-VA Medical Care Experience
The next set of questions explores several general topics of your experience and offers an opportunity for you to
provide suggestions.
17. How do you prefer to receive information about Non-VA Medical Care?
� Mail
� Electronic Mail (email)
� Phone
� Website
� Local VA facility visit
� Other (please specify) (text box)
18. How satisfied are you with the quality of the information provided about Non-VA Medical Care?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
� N/A
19. Overall, how satisfied were you with your Non-VA Medical Care experience?
� Strongly Satisfied
� Satisfied
� Neither Satisfied nor Dissatisfied
� Dissatisfied
� Strongly Dissatisfied
20. Please use the text box below to notate any suggestions on how Non-VA Medical Care can be improved:
(large text box)
21. If you would like to be contacted regarding your recent visit to a Non-VA Medical Care provider, please provide
your full name and phone number:
Name (text box)
Phone number (text box)
END OF SURVEY.

WE APPRECIATE YOUR TIME. THANK YOU!

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VA Form
OCT 2013

10-211013