2900-0770 State Veterans Home Patient Satisfaction

OMB No. 2900-0770

Estimated Burden: 2.5 Minutes

OMB Expiration Date: XX/XX/XXXX

State Veterans Home

Patient Satisfaction Survey

VA Form 10-10122

The Paperwork Reduction Act of 1995: 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 2.5 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve improved mental health services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may currently be receiving.

Rating Scale on Survey Monkey:

1 – poor

2 – fair

3 – good

4 – excellent

Questions – SVH Administrators for Ascellon Contractors

1. Please rate the level of professionalism of the Ascellon contractors.

2. Please rate the communication skills of the Ascellon contractors.

3. Please rate the level of interaction of the Ascellon contractors with the SVH leadership team.

4. Please rate the level of interaction of the Ascellon contractors with the facility staff.

5. Please rate the level of interaction of the Ascellon contractors with the residents.

6. Please rate your determination of the Ascellon contractors knowledge and interpretation of the VA regulations or VA standards

7. How well did the Ascellon contractors execute the daily schedule including the daily and entrance and exit briefings

8. Was ample opportunity given to the SVH by Ascellon contractors to explain their survey concerns

9. At the final exit conference; did the Ascellon contractors present their findings in a clear and concise manner and allowed an opportunity for questions. (Add box for additional comments)

10. What would you like to share about the Ascellon contractors in the survey experience? (open text box)

Questions – SVH Administrators for VA

1. Please rate the level of professionalism of the VA Medical Center Representative?

2. Please rate the level of professionalism of the VA Fiscal Representative?

3. Please rate the communication skills of the VA Team?

4. Please rank the level of professionalism and leadership at the opening entrance conference?

5. Please rate the level of interaction of the VA Team with the SVH leadership team?

6. Please rate your determination of the VA Team’s knowledge and interpretation of the VA regulations or VA standards?

7. How well did the VA Team execute the daily schedule including the daily and entrance and exit briefings?

8. Was ample opportunity given to the SVH by the VA Team to explain their survey concerns?

9. At the final exit conference; did the VA Team present their findings in a clear and concise manner and allowed an opportunity for questions? (Add box for additional comments)

10. What would you like to share about the VA Team in the survey experience? (open text box)