Non-VA Behavioral Health Care

Satisfaction Survey – Non-VA Care

OMB No. 2900-0770
Estimated Burden: 10 minutes

Expiration Date: 08/31/2017

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 10 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 Veteran centered 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-
APR 2014

Dear Veteran,

Our records indicate that you have had one or more behavioral health treatment sessions via the Choice program. We want your opinion of the quality of services you received from your community behavioral health provider. Please complete the enclosed survey questionnaire, choosing the best rating or select true or false for each question. Completing any portion of this questionnaire is completely voluntary and will in no way affect your access to the Choice program or any other VA benefit.

We appreciate your time and effort in helping us improve the quality of care you and other Veterans receive.

___________________________________

H. M. Cunningham, Ph.D.

­­­­­­­­­­­­­­­­­

___________________________________

Glenda Blake, RN

1. It was easy to schedule an appointment for Non-VA Behavioral Health Care.

Easy 1 2 3 4 5 Hard

2. I got an appointment in a reasonable time frame.

Quickly 1 2 3 4 5 Slow

1. Approximate number of days to get an appointment ___________ Days

1. My provider offers after-hours care when I need it. [ ] Yes [ ] No

2. When I go to my appointments, my provider sees me:

   1. Right away

   2. In less than 15 minutes

   3. 16 – 30 minutes

   4. More than 30 minutes

   5. I feel like the wait is: [ ] Just right [ ] Too long

3. My provider spends the appropriate amount of time with me. [ ] Yes [ ] No

4. The office staff treats me well.

Satisfied 1 2 3 4 5 Dissatisfied

7. The office is comfortable, clean etc.

Comfortable 1 2 3 4 5 Not comfortable

8. How well does the staff explain your condition and treatment options in a way you can understand?

Understandable 1 2 3 4 5 Not understandable

9. How much do you trust this provider's decisions?

Trust them 1 2 3 4 5 Do not trust them

10. Do you receive adequate medication information from your physician or other provider?

[ ] Yes [ ] No

11. Please rate the quality of care you receive from your provider.

High quality 1 2 3 4 5 Low quality

12. What does your provider do well? Select all that apply:

    1. Provide clear explanations

    2. Listens to me

    3. Is aware of my medical/mental health history

    4. Is friendly and respectful

    5. Answers my questions clearly

    6. Is not rushed

    7. Other, please explain ___________________________________________________

13. Assume the VA could get you scheduled within 30 days:

[ ] I would rather see someone at the VA [ ] I prefer to see my non-VA provider

14. Do you have a phone number to call if you have questions or concerns? [ ] Yes - [ ] No

15. Do you have an emergency phone number in case you have a crisis? [ ] Yes - [ ] No

16. Would you like to speak to a VA Staff member about any questions or concerns?

[ ] Yes [ ] No

17. Has your Choice provider requested that you pay any fee? [ ] Yes - [ ] No

Now think about your experiences with all the services provided by the Department of Veterans Affairs (which include healthcare, benefits programs, or memorial services). Please tell us how you feel about the following statements

1. “I got the service I needed.”

[ ] Strongly disagree [ ] Disagree [ ] Neither Agree nor Disagree [ ] Agree [ ] Strongly Agree

2. “It was easy to get the service I needed.”

[ ] Strongly disagree [ ] Disagree [ ] Neither Agree nor Disagree [ ] Agree [ ] Strongly Agree

3. “I felt like a valued customer.”

[ ] Strongly disagree [ ] Disagree [ ] Neither Agree nor Disagree [ ] Agree [ ] Strongly Agree

4. “I trust VA to fulfill our country’s commitment to veterans.”

[ ] Strongly disagree [ ] Disagree [ ] Neither Agree nor Disagree [ ] Agree [ ] Strongly Agree

Thank you for your participation in this survey.

5