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pdfOMB 2900-0770
Estimated Burden: 15 minutes
DEPARTMENT OF VETERANS AFFAIRS
OFFICE OF MENTAL HEALTH VETERAN SATISFACTION 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 this Act. Accordingly, we may not con duct or sponsor and you are not
required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who complete this survey will average 15 minutes. This includes the time it will take to read
information provided and gather the necessary facts to fill out the form. Submission of this form is voluntary and failure
to respond will have no impact on benefits to which you may be entitled. Responses to the survey will be reported in
aggregate form and will be anonymous.
For each item identified below, circle the number
to the right that best fits your judgment of its occurrence at your facility.
Use the scale above to select the frequency number.
Survey Item
1.
I get appointments with my mental health provider on the day
that I want or within two weeks of the day that I want
Strongly
Disagree
Neither
Disagree Disagree or
Agree
Agree
Strongly
Agree
NA or
Unknown
1
2
3
4
5
NA
2.
I can see my mental health provider who prescribes my
medications as frequently as needed
1
2
3
4
5
NA
3.
If I have a question about my psychiatric medications, I can
get in touch with a mental health provider or pharmacist by
phone to get my question answered
1
2
3
4
5
NA
4.
I talk to the person who prescribes my mental health
medication by Telemental health (V-Tel)
1
2
3
4
5
NA
5.
I talk to my counselor/therapist by Telemental health (V -Tel)
1
2
3
4
5
NA
6.
There are problems getting the Telemental health (V -Tel)
equipment to work
1
2
3
4
5
NA
7.
Mental health treatment has been helpful in my life
1
2
3
4
5
NA
8.
I was able to choose which of the psychotherapies I wanted to
try after good discussion with my mental health provider about
the options
1
2
3
4
5
NA
I believe it is necessary for me to stay in mental health
treatment to keep my service connected disability
1
2
3
4
5
NA
10. I would like to schedule mental health appointments during
extended hours (early mornings, evenings, or on weekends)
1
2
3
4
5
NA
11. It is hard to get to my mental health appointments because of
transportation problems
1
2
3
4
5
NA
12. Parking is a problem at my facility
1
2
3
4
5
NA
13. My mental health appointments are scheduled by VA without
any input from me
1
2
3
4
5
NA
14. I get a reminder call or letter about my mental health
appointments
1
2
3
4
5
NA
15. I attend group mental health treatment, and the room
comfortably fits all the group participants
1
2
3
4
5
NA
16. When I have an individual mental health session with my
provider, we meet in a room that is private
1
2
3
4
5
NA
17. I know that I will get a call back if I leave a message for my
mental health provider
1
2
3
4
5
NA
18. My mental health provider and I agree on how often I should
have appointments
1
2
3
4
5
NA
19. I can’t see my mental health provider as much as I should
because the provider does not have time to see me
1
2
3
4
5
NA
1
2
3
4
5
NA
9.
20. I am comfortable in the waiting area for mental healthcare
VA Form 10-0554
JULY 2012
OMB 2900-0770
Estimated Burden: 15 minutes
DEPARTMENT OF VETERANS AFFAIRS
OFFICE OF MENTAL HEALTH VETERAN SATISFACTION SURVEY
Strongly
Disagree
Disagree
Neither
Disagree or
Agree
Agree
Strongly
Agree
NA or
Unknown
21. The staff is open to my suggestions regarding improvements to
mental health services
1
2
3
4
5
NA
22. I am treated with respect and kindness at the mental health
programs
1
2
3
4
5
NA
23. During our appointments, my mental health provider focuses
on the computer rather than engaging with me in face-to-face
eye contact
1
2
3
4
5
NA
24. I know that there are mental health providers available right
in Primary Care
1
2
3
4
5
NA
25. My primary care provider prescribes my psychiatric
medications, such as medicine to help with depression or
nervousness
1
2
3
4
5
NA
26. My family has been involved in mental health treatment with
me as much as I would like them to be involved
1
2
3
4
5
NA
Survey Item
WRITE IN SECTION:
27. My Mental Health Treatment Coordinator is:___________________________________________________________
28. The biggest problem or concern I have about Mental Health Treatment is:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
29. The biggest compliment or positive I have about Mental Health Treatment is:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
If you wish to discuss your experience, please feel free to contact your Mental Health Treatment Coordinator, facility
Mental Health Chief, Local Recovery Coordinator, or other Mental Health staff.
VA Form 10-0554
JULY 2012
| File Type | application/pdf |
| Author | Microsoft Corporation |
| File Modified | 2013-05-31 |
| File Created | 2013-05-31 |