Mental Health - SORCC

VA SORCC MHSL Satisfaction Survey

OMB No. 2900-0770
Estimated Burden: 2.5 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 2.5 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 mental health services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

(<MH SERVICE/PROGRAM>) Customer Service Evaluation Date: ___________

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

If you rated your provider less than a score or 9 what could we have done to make your experience better?

Please tell us how you feel about the following statements:

2. “I know that I will get a call back if I leave a message for my MH provider”

Strongly Agree _____ Agree _____ Neither Agree nor Disagree _____ Disagree _____ Strongly Disagree _____ NA _____

3. “I can’t see my MH provider as much as I should because the provider does not have time for me”

Strongly Agree _____ Agree _____ Neither Agree nor Disagree _____ Disagree _____ Strongly Disagree _____ NA _____

4. “During our appointments my mental health provider focuses on the computer rather than with me in face-to-face eye contact”

Strongly Agree _____ Agree _____ Neither Agree nor Disagree _____ Disagree _____ Strongly Disagree _____ NA _____

5. “My MH provider and I agree on how often I should have appointments”

Strongly Agree _____ Agree _____ Neither Agree nor Disagree _____ Disagree _____ Strongly Disagree _____ NA _____

6. “I got the service I needed”

Strongly Agree _____ Agree _____ Neither Agree nor Disagree _____ Disagree _____ Strongly Disagree _____ NA _____

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

Strongly Agree _____ Agree _____ Neither Agree nor Disagree _____ Disagree _____ Strongly Disagree _____ NA _____

8. “I felt like a valued customer”

Strongly Agree _____ Agree _____ Neither Agree nor Disagree _____ Disagree _____ Strongly Disagree _____ NA _____

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

Strongly Agree _____ Agree _____ Neither Agree nor Disagree _____ Disagree _____ Strongly Disagree _____ NA _____

Comments (Please include anything you think would be helpful for improving this therapy or any general comments):

*** Please note that this evaluation originated at the VA SORCC and you may still receive additional surveys from National VHA. A response to any VA Survey is appreciated and helps to ensure you are receiving the highest quality of care.

Thank you for your willingness to respond. ***