Primary Care Satisfaction and Effectiveness Survey

Primary Care Service Satisfaction/Effectiveness Questionnaire

OMB No. 2900-0770
Estimated Burden: 2 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 2 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.

Primary Care Service Satisfaction/Effectiveness Questionnaire

We would like to know your satisfaction of your Primary Care experience. Please answer the questions below. Thank you.

Date: _______________________

Your Primary Care Team:______________________________________________

Please circle the response that best describes your experience with this activity.

1. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate the provider you saw today?

Circle your rating:

0 1 2 3 4 5 6 7 8 9 10

2. What can we do to improve services?

Please tell us how you feel about the following statements.

“I got the service I needed”.

Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree ______ Agree _____ Strongly Agree ______

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

Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree ______ Agree _____ Strongly Agree ______

“I felt like a valued customer”.

Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree ______ Agree _____ Strongly Agree ______

I trust the VA to fulfill our country’s commitment to Veterans”.

Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree ______ Agree _____ Strongly Agree ______

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