MFH Veteran Survey

Medical Foster Home Veteran Survey

OMB No. 2900-0770
Estimated Burden: 5 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 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 services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VETERAN Annual MFH Satisfaction Survey

The VA MFH program would like to ask you some questions. We ask that you be open and truthful with your answers to best help us serve you going forward.  This information will be used to help us identify our strengths, and areas we can improve.  You can choose to provide your name, or remain anonymous. Either way - your feedback is valued, your opinion is very important. Please circle your preferred response where indicated.

Veteran’s name (optional): ___________________________________________________ Date: ___________________

1. Veteran’s current age:

21-35 36-45 46-55 56-65 66-75 76-85 86-95 96+

2. Length of time you have been with this MFH caregiver?

1-6 mos 7-12 mos 1-2 yrs 2-3 yrs 3-4 yrs 4-5 yrs 5-6 yrs 6-7 yrs 7-8 yrs 8-9 yrs 9-10 yrs 10+ yrs

Respond to the following statements:

3. ‘I got the service I needed’

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

4. ‘It was easy to get the service I needed’

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

5. ‘I felt like a valued customer’

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

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

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

7. ‘My MFH caregiver maintains a very clean home setting for me to live’.

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

8. ‘As a MFH Veteran, I am provided adequate opportunity for privacy’.

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

9. ‘This MFH is not excessively noisy most of the time’.

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

10. ‘I am pleased with the quality, variety, and freshness of the meals and snacks I eat’.

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

11. ‘I am overall pleased with living in this home, and presently choose to remain here.’

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

12. ‘When I request assistance from my caregiver, she/he responds quickly’.

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

13. ‘My caregiver is very compassionate, and provides a loving and supportive home to provide the care that I need’.

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

14. ‘I have been pleased with the frequency and variety of leisure outings provided to me’.

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

15. ‘I have been pleased with the amount of support and responsiveness of the MFH Coordinator.’

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

16. ‘The VA home care team (physician, nurse, dietician, therapist, social worker, etc.) is very courteous, timely in assisting me, and respects me as a Veteran’.

Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree

17. Any additional comments or recommendations:______________________________________________________

________________________________________________________________________________________________________

18. Individual who completed this feedback request:

Veteran Veteran w/family Veteran w/caregiver Family of Veteran Veteran w/VA staff Other

Thank you! UPDATED: 9/20/16