Form VA Form 10-0495 VA Form 10-0495 Understanding PTSD for Family Caregivers: Feedback Surve

OMB 2900-XXXX
Estimated Burden 10 minutes

Expiration Date: XX/XX/XXXX

Department of Veterans Affairs

Veterans Health Administration

Understanding PTSD for Family Caregivers: Feedback Survey

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 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Customer satisfaction surveys are used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this survey will lead to improvement in the quality of service delivery by helping to shape the direction and focus of specific programs or services. Completion of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

1) PURPOSE OF SURVEY: VA is interested in feedback on the education programs it offers to Caregivers. Please take a moment to let us know your thoughts on the education program you recently attended as well as suggestions for future Caregiver education programs.

2) SELECTION: You were selected to receive this survey because you attended the Understanding PTSD for Family Caregivers program.

3) TIME: The survey is estimated to take 10 minutes to complete.

4) QUESTIONS: For content-related questions, please contact Paul Holmes at [email protected]

5) HELP: If you have technical difficulty with this survey, please send a message to [email protected]

_{How would you describe your role as a Caregiver?}

^{ Spouse}

^ Parent

^{ Child}

^ Friend

^{ Other}

Please type in your role:

Please indicate your level of agreement with the following statements regarding the "Understanding PTSD for Family Caregivers" program.

Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree

I would recommend this program to other
Caregivers of Veterans

The content presented met my needs.

The setting was conducive to my ability to learn.

I learned something new from the training program

I was satisfied with the length of this Caretaker
Education program

I was satisfied with the format of this Caregiver
Education Program

Overall, I was satisfied with the program.

Please check the top three ways you would like future Caregiver education programs to
be delivered.

Live Broadcast with other Caregivers participating

Webinar at a VHA site with other Caregivers participating

Webinar accessed from home computer

Telephone Conference call with Power Points

Live Stream to home computer

Other

What other way would you like future Caregiver education programs to be delivered?

The "Understanding PTSD for Caregivers" program provided information on the following topics. Please indicate both the level of usefulness of each of the topics below as well as whether you have had an opportunity to utilize any of the suggested strategies.

Did you try to use this information after attending the program?

Usefulness of Information

_{Common Barriers to} ^{Treatment (lack of} awareness, stigma, fear)

c

^{Resiliency (social support, role models, purpose)}

_{PTSD Symptoms & Triggers} (irritability, withdrawal, TV, crowding)

^{Not Somewhat Moderately Useful Very Not
Useful Useful Useful Useful Applicable}

^{Responses to Nightmares}

^{(calm voice, no touching)}

_{Responses to Anger}
^{(understand cause no}
confrontation)

Stress Management

^{(relaxation exercises,}
practice together daily)

Grounding (focus on the here
and now)

_{Treatment Options (trauma}

^{focused, family and couples}
therapy etc.)

_{Please indicate the level of importance for the following components of the Caregiver education program.}

Please rank the importance of the following topics to your individual needs. Please indicate your ranking from 1 to 5 with "1= Most Important" and "5= Least Important". Please use each number only once.

Children living with a Parent with PTSD

Traumatic Brain Injury

Respite Care

Education Benefits for Veterans Caregivers and Children

Employment

If you think there are other topics that should be considered for future Caregiver programs, please specify below.

How often should we provide these trainings?

The "Question and Answer" section of the program

The presence of a VA mental health provider at your group meeting

The presence of other Caregivers in the room

^{Not Very Somewhat Moderately Important Very Important Important Important Important}

VA Form 10-0495
SEP 2012