VA form 10-0519 Notice Your Nurse

Veterans Health Administration

Notice Your Nurse

Please take a moment to recognize a nurse who you feel made your stay here at the VA Medical Center a bit more comfortable.

Name of a nurse who you felt provided you with EXCEPTIONAL care during your stay (Please list someone other than your primary nurse):______________________

Please describe why you chose this individual:_______________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Your name (OPTIONAL):__________________________

VA FORM 10-0519 OMB No. 2900-XXXX

May 2011 Estimated Burden: 5 min.

Expiration: XX/XX/XXXX

Back of Card

This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct 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 5 minutes. This includes the time it will take to read and fill out the comment card. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. Completion of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

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VA FORM 10-0519 OMB No. 2900-XXXX

May 2011 Estimated Burden: 5 min.

Expiration: XX/XX/XXXX