VHA Pallative Care Telehealth Appointments / Mental Health Veterans Survey

Veterans' and Provider's User Experience of
Palliative Care Telehealth Appointments
OMB No. 2900-0769
Estimated Burden: 10 minutes

Expiration Date: 08/31/XXXX

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 survey will lead to improvements in the
quality of service delivery by helping to achieve more accessible telehealth services for Veterans.
Participation in this survey is voluntary and failure to respond will have no impact on benefits to which
you may be entitled.

System Usability Scale
© Digital Equipment Corporation, 1986.
Instructions: This survey is about your palliative care telehealth experience. Please rate how much you
either agree or disagree with the following statements about the telehealth appointment by placing an X in
the box that indicates your opinion.

Strongly
disagree
1. I think that I would like to
use this system frequently

Strongly
agree

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

2. I found the system unnecessarily
complex

3. I thought the system was easy
to use

4. I think that I would need the
support of a technical person to
be able to use this system

5. I found the various functions in
this system were well integrated

6. I thought there was too much
inconsistency in this system

7. I would imagine that most people
would learn to use this system
very quickly
8. I found the system very
cumbersome to use

9. I felt very confident using the
system

10. I needed to learn a lot of
things before I could get going
with this system

Demographic Questions
1.) In what year were you born? ______
2.) Are you Hispanic, Latino, or of Spanish origin?
a. No, not of Hispanic, Latino, or Spanish origin
b. Yes, of Hispanic, Latino, or Spanish origin
c. Unavailable/Unknown
d. Declined
3.) What race do you most identify with (circle all that apply)?
a. Black or African-American
b. White
c. American Indian /Alaskan Native
d. Asian
e. Native Hawaiian /Pacific Islander
f. Other:_________________________
4.) What gender do you most identify with?
a. Female
b. Male
c. Other: ________________________
5.) Location during Telehealth Appointment: ______________________
6.) Technology used for Telehealth Appointment (check all that apply):
__ Ipad/Tablet
__ Laptop Computer
__ Desktop Computer
__ Smart Phone
__ Other: _____________________
7.) Technologies used outside of telehealth appointments (check all that apply):
__ Computer
__ Ipad/Tablets
__ Smart Phone
__ Other
8.) How would you rate your general comfort with the technology in your life on a 1-10 scale (not
including the telehealth appointments)? (One being very uncomfortable and ten being very
comfortable). ___
9.) What is the highest level of school you have completed or the highest degree you have received?
a. Less than high school degree
b. High school degree or equivalent (e.g., GED)
c. Some college but no degree
d. Associate degree
e. Bachelor degree
f. Graduate degree