VA Form 10-0508a SSVF Participant Satisfaction Survey

OMB 2900-XXXX
Estimated Burden 15 minutes

Supportive Services for Veteran Families
(SSVF) Program

Participant Satisfaction Survey

Paperwork Reduction Act: 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 completing and reviewing the collection of
information. Respondents should be aware that notwithstanding any other provision of law,
no person will 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. Response to this
survey is voluntary and failure to participate will have no adverse effect on benefits to
which you might otherwise be entitled.

VA Form
April 2011

10-0508a

OMB Control Number:

Supportive Services for Veteran Families (SSVF) Program
Participant Satisfaction Survey
To assist VA in improving the SSVF Program, please complete this form and mail it back (postage pre-paid)

/

Date

/

Name of provider:
Number of individuals in household:

1

2

3

4+

Number of individuals in household receiving support services from this provider:
Yes
No
Are you enrolled in the VA health care system?
Is this the first or second time completing this survey?

First

1

2

3

4+

Second

1. How would you rate the quality of the services you have received from this supportive services provider?
Extremely Poor
Below Average
Average
Above Average
Excellent
2. If another Veteran or a friend were in need of similar help, would you recommend this supportive services
provider to him or her?
Definitely Not
Probably Not
Probably So
Definitely
3. How satisfied are you with the services you have received from this supportive services provider?
Very Dissatisfied
Dissatisfied
Neither Satisfied Nor Dissatisfied
Satisfied
Very Satisfied
4. If you needed help again and had a choice of where to go at no cost to you, would you return to this supportive services
provider?
Definitely Not
Probably Not
Probably So
Definitely
5. Did the supportive services provider involve you in creating an individualized housing stabilization plan?
Yes
No
6. If you answered Yes to Question 5, do you feel that this housing plan is a good fit for your needs?
Yes

No

7. Is there any other feedback about the supportive services provider that you wish to provide to the VA?

8. In the following table, please indicate which supportive services you received and indicate the quality of the
supportive services received.
Supportive Services
1. Case Management
2. Assistance in
obtainng VA Benefits

Did you need
this service?
Yes
No
Yes
No

Did you receive
What was the quality of the service?
this service?
Yes
No
Extremely Poor Below Average Average
Above Average
Yes
No

Extremely Poor

Excellent

Below Average

Average

Above Average

Excellent

3. Assistance in obtaining & coordinating other public benefits
a. Health care

Yes
No

Yes
No

Extremely Poor

Below Average

Average

Above Average

Excellent

b. Daily living

Yes
No

Yes
No

Extremely Poor

Below Average

Average

Above Average

Excellent

c. Personal financial
planning

Yes
No

Yes
No

Extremely Poor

Below Average

Average

Above Average

Excellent

d. Transportation

Yes
No

Yes
No

Extremely Poor

Below Average

Average

Above Average

Excellent

Yes
No

Yes
No

Extremely Poor

Below Average

Average

Above Average

Excellent

e. Income support
VA Form
April 2011 10-0508a

4581649300

Did you need
this service?
Yes
No
Yes
No

f. Legal
g. Child care
h. Housing counseling

Did you receive
this service?
Yes
Extremely Poor
No

Yes
No

Yes
No
Yes
No

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

What was the quality of service?
Below Average

Average

Above Average

Excellent

Extremely Poor

Below Average

Average

Above Average

Excellent

Extremely Poor

Below Average

Average

Above Average

Excellent

Extremely Poor

Below Average

Average

Above Average

Excellent

Extremely Poor

Below Average

Average

Above Average

Excellent

Extremely Poor

Below Average

Average

Above Average

Excellent

Extremely Poor

Below Average

Average

Above Average

Excellent

Extremely Poor

Below Average

Average

Above Average

Excellent

Extremely Poor

Below Average

Average

Above Average

Excellent

4. Other Supportive Services
a. Rental assistance
b. Utility fee payment
assistance
c. Security and utility
deposits
d. Moving costs
e. Purchase of
emergency supplies
f. Other:

Please answer questions 9 - 14 if you have recently begun receiving services from this provider. You do not
need to answer these questions if this is the second time you are completing this survey.
9. Have you ever lived in one of the following places?
Yes
Yes
Yes
Yes
Yes

No On the street or a place not meant for human habitation
No In your car, boat, or an abandoned building
No Emergency shelter or drop-in center
No Transitional housing or halfway house
No Hotel/motel, Single Room Occupancy (SRO), Safe Haven

Yes

No In a family or friend's apartment or house because you had nowhere else to go
10. If you answered Yes to any of the places listed in Question 9, on how many separate occasions did you sleep in one of
those places?
1 time
2-5 times
6-10 times
More than 10 times
11. How many times did you move in the year before you requested help at this program?

0

1

2

3+

12. In the year before you requested help from this supportive services provider, was there a time when your income
decreased so much that it became hard to pay your housing costs?
Yes
No
13. Did your employment status (employed full time, employed part time, unemployed) change significantly in the year before
Yes
No
you requested help from this supportive services provider?
14. If you answered Yes to Question 13, did you start working or stop working?

Start Working

Stop Working

Please answer questions 15 - 18 if you are no longer receiving services from this provider or will no longer be
receiving services from this provider in the immediate future. You do not need to answer these questions if you
answered questions 9-14.
15. How many times have you moved since you started receiving services from this provider?

0

1

2

3+

16. Since you started receiving services from this supportive services provider, was there a time when your income
decreased so much that it became hard to pay your housing costs?
Yes
No
17. Has your employment status changed significantly (employed full time, employed part time, unemployed) since you
started receiving services from this supportive services provider?
Yes
No
18. If you answered Yes to Question 17, did you start working or stop working?

Start Working

Stop Working

Please place your completed survey in the envelope provided, seal the envelope and return it in accordance with the instructions you
were given at the time you received the survey. Do not place your name on this survey or on the envelope. Thanks for your feedback.
If you have any questions, please feel free to contact the SSVF Program Office at 1-877-737-0111 or via e-mail at [email protected] or
visit http://www.va.gov/homeless/ssvf.asp.
VA Form
6422649306
April 2011 10-0508a