VA Form 10-211011 Dental Insurance Program Survey

OMB 2900-0770
Estimated Burden: 15 min.

Department of Veterans

Dental Insurance Program 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
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. No person will be penalized for failing to furnish this
information if it does not display a currently valid OMB control number. Your obligation to respond to this survey is voluntary and failure
to furnish this information will have no effect on any benefits you are entitled.

Q1 Who did you select as your dental provider?
Delta Dental...........................................................
MetLife...................................................................
Q2 How would you describe the area where you
live?
Urban (greater than 1000 people per square
mile).......................................................................
Rural (8 to 999 people per square mile)...............
Highly rural (less than 8 people per square mile).
Q3 How reasonable was the distance you had to
travel to the dental provider?
Very reasonable.....................................................
Reasonable ...........................................................
Neither reasonable or not reasonable....................
Fairly reasonable ...................................................
Not reasonable at all..............................................
Q4 Would you please provide your age?

Q7 Would you recommend VA Dental Insurance
Program to another Veteran?
Yes ........................................................................
No ..........................................................................
Q8 Would you like to see your family included in
the program?
Yes ........................................................................
No ..........................................................................
N/A ........................................................................
Q9 Please rate your overall satisfaction with the
VA Dental Insurance Program.
Excellent ................................................................
Very good ..............................................................
Good......................................................................
Fair ........................................................................
Poor .......................................................................
Q10 If your satisfaction is not excellent or very
good please tell us why.

Less than 30 ..........................................................
30 to 40 .................................................................
41 to 50 .................................................................
51 to 60 .................................................................
61 to 70 .................................................................
Greater than 70 ......................................................
Q5 How satisfied are you with how well the Dental
plan met your dental needs?
Highly Satisfied ......................................................
Very Satisfied .........................................................
Neither Satisfied or dissatisfied ............................
Fairly Satisfied .......................................................
Not Satisfied at all..................................................
Q6 Considering premiums and out of pocket costs,
how would you describe the value of the VA Dental
Insurance Program?
Excellent ................................................................
Very good ..............................................................
Good......................................................................
Fair ........................................................................
Poor .......................................................................
VA Form
DEC 2013

10-211011

Q11 Do you plan on renewing your coverage
under the VA Dental Insurance Program?
Yes ........................................................................
No ..........................................................................

Q12 Please provide us any comments to improve
the Dental program.