Form 10-10129 Extended Hours Evaluation - Non-Users

OMB Number 2900-0770

Estimated Burden: 4 mins

EXP Date: XX/XX/2014

Extended Hours Program Evaluation

Non-Users Survey

OMB 2900-0770

Estimated burden: 4 minutes

Expiration Date xx/xx/xxxx

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 four (4) 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 services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VA Form 10-10129

[Caller from VA]: Hello, my name is _______ and I’m calling from the _______ VA clinic. We are evaluating our Extended Hours Program for providing appointments in Primary Care, which means an appointment in Primary Care either before 8 AM or after 4:30 PM on a weekday, or on a Saturday. Our records indicate that you recently had an extended hours appointment. Do you have a few minutes to complete a very brief survey with me on the phone?

• Yes

• No  Thank you for your time. I hope you have a nice day!

The questions I want to ask you today are about Extended Hours appointments, which are those that occur:

• Before 8:00 AM on weekdays

• After 4:30 PM on weekdays

• And on Saturdays

1. Are you aware that this clinic provides scheduled primary care appointments during extended hours?

• Yes

• No [Skip to Question 3]

2. How did you learn about the availability of extended hours appointments? (Check all that apply.)

• I asked for an appointment during extended hours

• It was offered when I arranged my appointment

• I heard about them from a friend or family member

• I heard about them from a Veterans Service Organization, such as the DAV (Disabled American Veterans) or VFW (Veterans of Foreign Wars)

• I read about them

• Other (please specify) ________________________________________

3. Are you interested in having primary care appointments during extended hours?

• Yes

• No [Skip to Question 5]

4. Can you tell us why you are interested in these times? (Check all that apply.)

• It fit with my work schedule

• It was the best time to get a ride

• It is easier to park

• There is less traffic

• Personal preference

• I couldn’t get an appointment when I wanted it during usual clinic hours
  (Weekdays, 8 AM - 4:30 PM)

• Other (please specify) ________________________________________

5. Can you tell us why you are not interested in extended hours appointments?
   (Check all that apply.)

• Traffic is bad

• Hard to get a ride

• The times are not convenient

• Don’t want to give up leisure time on weekends

• Interferes with work schedule

• Specialty appointments are not available then

• Other (please specify) ___________________________________________

6. If you could get appointments in other areas such as the eye clinic, audiology (hearing) clinic, or podiatry (foot) clinic during extended hours, how would that affect your willingness to have your primary care appointment during extended hours?

• More likely to request extended hours appointment

• No change in willingness

• Less likely to request extended hours appointment

7. Is there anything else you would like to share with us about extended hours appointments?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Thank you for taking the time to evaluate our extended hours program.

Your feedback is very valuable to us and will be used to improve our services.

Have a nice day!