VA Form 10-0545 Non-VA Care Coordination Veteran Satisfaction Survey

OMB 2900-XXXX
Estimated Burden 3 minutes

Expiration Date: XX/XX/XXXX

DEPARTMENT OF VETERANS AFFAIRS

VETERANS HEALTH ADMINISTRATION

NON-VA CARE COORDINATION
VETERAN SATISFACTION SURVEY

VA Form 10-0545

OMB 2900-0770

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. The purpose of the Non-VA Care Coordination (NVCC) Veteran Satisfaction Survey is to assess Veteran satisfaction with receiving non-VA care services through the Non-VA Care Coordination process as compared to obtaining non-VA care services through Fee basis processes utilized by VA medical centers prior to implementation of NVCC. The results of this survey will help VHA improve and standardize the process by which Veterans were referred for non-VA care services and coordination of that care. Completion of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

NON-VA CARE COORDINATION VETERAN SATISFACTION SURVEY

Thank you for taking the time to complete the Non-VA Care Veteran Satisfaction Survey. Non-VA care is health care for which Veterans are referred by their VA provider and the VA authorizes the care to be provided in the community. The survey should take less than 5 minutes to complete. Your responses are completely anonymous and private. There are 9 questions which are listed on the front and back of this sheet. For each question, please check the box that best matches your experience with obtaining non-VA care. Please return the completed survey in the enclosed, self-addressed, stamped envelope by August 15, 2012.

1. I was given an opportunity by VA staff to ask questions about my non-VA care.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

2. VA staff explained what to expect regarding my appointment with a non-VA care provider.
   

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

3. I was given an opportunity to see my non-VA care provider of choice.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

4. VA staff considered my personal wants and needs.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

PLEASE TURN PAGE OVER

5. Overall, it was not difficult to schedule a non-VA care appointment.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

6. Did a VA staff member contact you after your non-VA care appointment?

Yes No

If “YES”, answer question 7. If “NO”, skip question 7 and answer question 8.

7. I liked that a VA staff member contacted me after my non-VA care appointment.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

8. I would have liked a VA staff to contact me after my non-VA care appointment.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

9. Overall, I was satisfied with my non-VA care experience.

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

Comments: _________________________________________________________________________________________________________

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END OF SURVEY

PLEASE MAIL YOUR SURVEY IN THE ENCLOSED, SELF-ADDRESSED, STAMPED ENVELOPE. WE APPRECIATE YOUR TIME. THANK YOU!

VA Form 10-0545
MAR 2012