Form 10-0341 Care Coordination Home Telehealth (CCHT) Patient Satisfa

OMB 2900-0766
Estimated Burden: 1.5 min.
OMB EXP Date: XX/XX/XXXX

Care Coordination Home Telehealth (CCHT)
Patient Satisfaction 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
1.5 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. The following statement is related to your feelings about the Care Coordination staff. The staff is
helpful.
 Strongly agree (1)
 Agree (2)
 No opinion (3)
 Disagree (4)
 Strongly disagree (5)
 No Experience (6)
2. The following statement refers to the health care you receive from the Care Coordination program.
Information given to me about my health is clear and adequate.
 Strongly agree (1)
 Agree (2)
 No opinion (3)
 Disagree (4)
 Strongly disagree (5)
 No Experience (6)
3. Your Care Coordinator has a thorough understanding of the things that are wrong with you.
 Strongly agree (1)
 Agree (2)
 No opinion (3)
 Disagree (4)
 Strongly disagree (5)
 No Experience (6)
4. Please rate the following aspects of the health care you received from Care Coordinators in the past
12 months. Advice the Care Coordinator gives you about ways to avoid illness and stay healthy.
 Excellent (1)
 Very Good (2)
 Good (3)
 Fair(4)
 Poor(5)
 Not Applicable (6)
VA Form
DEC 2009

10-0481

5. How much do you agree or disagree with the following statement about the Care Coordination care
you have received in the past 12 months? I would recommend this type of care to my family or
friends who have chronic diseases.
 Strongly agree (1)
 Agree (2)
 No opinion (3)
 Disagree (4)
 Strongly disagree (5)
 No Experience (6)
6. Think about the care you receive from your Care Coordinator. You often have health problems that
should be discussed but are not.
 Strongly agree (1)
 Agree (2)
 No opinion (3)
 Disagree (4)
 Strongly disagree (5)
 No Experience (6)
7. The following statement refers to your Care Coordinator. It is easy to understand what the Care
Coordinator is talking about.
 Strongly agree (1)
 Agree (2)
 No opinion (3)
 Disagree (4)
 Strongly disagree (5)
 No Experience (6)
8. The information given by the Care Coordinator about my medical problems helps me to adjust to my
condition.
 Strongly agree (1)
 Agree (2)
 No opinion (3)
 Disagree (4)
 Strongly disagree (5)
 No Experience (6)

VA Form
DEC 2009

10-0481