Customer Satisfaction Survey for Claims Clinics Pilot Program

Claims Clinic Satisfaction Survey OMB Control No. 2900-0770

Respondent Burden: 5 minutes

Expiration Date: 08/31/2017

Thank you for participating in today’s claims clinic. We hope today’s event helped resolve your benefits issues and appreciate your participation in this survey to help us better serve yours and other Veteran’s needs. By understanding where we are exceeding your expectations or need improvement, we can allocate our resources to provide better service. Thank you for your time.

1. What was the purpose of your visit today? Check all that apply

	Disability Compensation		Home Loan		Pension		Vocational Rehabilitation
	Education		Appeals		Health Care		Burial Benefits

2. Prior to today’s Claims Clinic, were you registered on eBenefits? If not, did you register today?



Registered Prior



Not Registered



Registered Today

3. Prior to today’s Claims Clinic, were you registered on MyHealtheVet? If not, did you register today?



Registered Prior



Not Registered



Registered Today

4. How far did you travel in order to reach today’s Claims Clinic?



Less than 10 miles



10 to 40 miles



40 to 100 miles



More than 100 miles

5. How did you hear about today’s Claims Clinic?

	Friend		Family		Facebook		Veteran Service Org.
	Visited Previous Clinic		Television		Other _______________________________________

6. Would you recommend attending today’s type of event to other Veterans?



Yes



No

7. How have you previously contacted the VA with questions about benefits? Check all that apply



In person



Phone



Internet

8. Do you prefer asking questions about your benefits in person, over the phone, or on the internet?



In person



Phone



Internet

Please rate the following categories based on your satisfaction level (circle the number):

	Worst				Best
Overall quality of service received	1	2	3	4	5
Your wait time throughout event	1	2	3	4	5
Convenience of the date and time of event	1	2	3	4	5
Convenience of the event location	1	2	3	4	5
Quality of service from VA representatives	1	2	3	4	5

1. Comments / Testimonial:

Thank you very much for taking the time to complete this survey. Your feedback is valued and very much appreciated!

PAPERWORK REDUCTION ACT STATEMENT: This information collection meets the requirements of the Paperwork Reduction Act of 1995. We anticipate that the time required to complete this survey will average 5 minutes. This includes the time required to read the instructions and complete the form. This survey will be used to gauge customer satisfaction and perception of individuals attending Claims Clinics in order to assist in shaping the direction and focus of this specific program or service. Submission of this form is strictly voluntary and no personal information is required. All responses are used in combination with the responses of others participating in the survey.

Veteran Satisfaction Survey

Ticket Number__________________