Form VA Form 10-0151 VA Form 10-0151 Customer Modality Administrative Survey

OMB 2900-0761
Estimated Burden: 23 minutes

Customer Modality Administrative 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 23 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 current valid OMB control number. This collection of
information is intended to fulfill the need identified by the Department of Veterans Affairs in their call for evaluation and
improvements to the current Patient Satisfaction program. Your obligation to respond to this survey is voluntary and failure to
furnish this information will have no effect on any of your benefits.

1. If you were asked to provide financial information to establish your eligibility for VA
care, how would you prefer to submit the information? (Check all that apply)
A. Mail
B. Facsimile (FAX)
C. Secure Web Site
D. Kiosk at my VA Medical Center
E. In person at my VA Medical Center
2. If you were asked to provide insurance information, how would you prefer to submit
it? (Check all that apply)

A. Mail
B. Facsimile (FAX)
C. Secure Web Site
D. Kiosk at my VA Medical Center
E. In person at my VA Medical Center
F. Telephone
3. How would you prefer [CBO Organization] contact you to request your updated
information? (Check all that apply)

A. Telephone
B. Mail
C. Email
D. Secure Web Site
4. How would you prefer [CBO Organization] notify you about decisions affecting your
healthcare benefits - for example, decisions about your eligibility for care and
decisions about appeals? (Check all that apply)

A. Telephone
B. Mail
C. Email
D. Secure Web Site

VA Form 10-0151
May 2009

Customer Modality Survey Questions
Chief Business Office (CBO)

Page 1.

5. What do you consider a reasonable length of time for [CBO Organization] to take
before it notifies you about its decisions?
A. Less than 1 week
B. 1 week
C. 2 weeks
D. 3 weeks
E. 4 weeks or more
6. How often would you prefer to receive status updates on a pending issue or claim
that you have submitted to the [CBO Organization]?
A. Once a week
B. Every 2 weeks
C. Every 3 weeks
D. Once a month
7. What method would you prefer to receive a status update on a pending issue or
claim? (Check all that apply)
A. Mail
B. Email
C. Secure Web Site
D. Telephone
8. Which of the following types of information would you like [CBO Organization] to
provide to you? (Check all that apply)
A.Telephone numbers
B.Mailing Addresses
C.News bulletins
D.Website locations
E.Veterans Service Organization (VSO) contact information
F.Other
9. Do you believe Veterans should assist the [CBO Organization] in creating
information for all Veterans?
A.Yes
B. No
10. How would you suggest [CBO Organization] involve Veterans when it creates
forms to be used by Veterans? (Check all that apply)
A.Through Volunteer Services
B.Through VSOs
C.Other - specify
D.Not at all
VA Form 10-0151
May 2009

Customer Modality Survey Questions
Chief Business Office (CBO)

Page 2.

11. Please rate how important each of the following is to improving the
website? (Check all that apply)
A. Make it easier to read
Very important
Important
Neutral
Somewhat unimportant
Very unimportant
B. Make it easier to navigate
Very important
Important
Neutral
Somewhat unimportant
Very unimportant
C. Improve content
Very important
Important
Neutral
Somewhat unimportant
Very unimportant
D. Provide more links
Very important
Important
Neutral
Somewhat unimportant
Very unimportant
E. Make it easier to search for information
Very important
Important
Neutral
Somewhat unimportant
Very unimportant
F. Other - specify
VA Form 10-0151
May 2009

Customer Modality Survey Questions
Chief Business Office (CBO)

Page 3.

12. What method would you prefer to use when updating your personal information?
(Check all that apply)
A. Mail
B. Facsimile (FAX)
C. Email
D. Secure Web Site
E. Kiosk at my VA Medical Center
F. In person at my VA Medical Center
13. What method would you prefer to use when checking in for an appointment at a
VA health care facility? (Check all that apply)
A.
B.
C.
D.

Kiosk at my VA health care facility
In person at my VA health care facility
Secure Web Site
Other

14. What method would you prefer to use when obtaining preauthorization for special
medical supplies and medical care services? (Check all that apply)
A. Mail
B. Secure Web Site
C. Email
D. Kiosk at my VA Medical Center
E. In person at my VA Medical Center
F. Telephone
15. How do you prefer to contact the [CBO Organization]? (Check all that apply)
A. Telephone
B. Mail
C. Email
D. Online Chat
E. Secure Web Site
F. Other
16. If you had questions about your VA billing statement, when would you be most
likely to call about your questions?
A. The day you receive the statement
B. 2-to-3 days after you receive the statement
C. 4-to-5 days after you receive the statement
D. More than 5 days after you receive the statement
VA Form 10-0151
May 2009

Customer Modality Survey Questions
Chief Business Office (CBO)

Page 4.

17. When you call with questions about a [VA billing statement] and you think the
wait will be long, are you more likely to:
A. Stay on hold
B. Call back later
C. Try another method of contact
18. To pay your bill, would you rather: (Check all that apply)
A. Pay by telephone
B. Pay using online banking
C. Mail your payment
D. Pay in person
19. How often would you be willing to take a survey to help improve the services
[CBO Organization] provides Veterans?
A. Once a month
B. Twice a year
C. Once a year
D. Other
20. What can we do to make your experiences with the [CBO organization] better?
[CBO Organization is a generic term for any CBO program office

VA Form 10-0151
May 2009

Customer Modality Survey Questions
Chief Business Office (CBO)

Page 5.