VA Form 10-10072a SSVF Participant Satisfaction Survey

OMB 2900-0757
Estimated Burden 15 minutes

Supportive Services for Veteran Families (SSVF)
Program

Participant Satisfaction Survey

Paperwork Reduction Act: This information collection is in accordance with the clearance requirements
of Section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of
information is estimated to average 15 minutes per response, including the time for completing and
reviewing the collection of information. Respondents should be aware that notwithstanding any other
provision of law, no person will be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number. Response to this survey is
voluntary and failure to participate will have no adverse effect on benefits to which you might otherwise be
entitled.

VA Form 10-10072a
April 2011

OMB Control Number:

Supportive Services for Veteran Families (SSVF) Program Participant Satisfaction Survey
Thank you for your willingness to complete this survey about the services you have received. Your responses will be
used by VA to better understand the effectiveness of the program and where services might be either kept the same,
or changed, to help other Veterans and their families. All answers you provide on this survey are confidential as survey
data does not include names.
Name of provider (Organization that provided you with SSVF Services):
1

3

4+

Is this the first or second time completing this survey?

First

Number of individuals in household:

2

Are you enrolled in the VA health care system?

Yes

No
Second

1. How would you rate the quality of the services you have received from this supportive services provider?
Poor
Average
Good
Excellent
2. If another Veteran or a friend were in need of similar help, would you recommend this supportive services
provider to him or her?
Definitely Not
Probably Not
Probably So
Definitely

3. If you needed help again would you return to this supportive services provider?
Definitely Not

Probably Not

Probably So

Definitely

4. Did the supportive services provider involve you in creating an individualized housing stabilization plan?
Yes
No
4A. If you answered Yes to Question 5, do you feel that this housing plan is a good fit for your needs?
Yes

No

5. Is there any other feedback about the supportive services provider that you wish to provide to the VA?

6. In the following table, please indicate which supportive services you received and indicate the quality of the
supportive services received.
Supportive Services
1. Case Management
2. Assistance in
obtainng VA Benefits

Did you need
this service?
Yes
No
Yes
No

Did you receive
this service?
Yes
No
Yes
No

What was the quality of the service?
Poor

Average

Good

Excellent

Poor

Average

Good

Excellent

3. Assistance in obtaining & coordinating other public benefits
a. Health care

Yes
No

Yes
No

Poor

Average

Good

Excellent

b. Daily living

Yes
No

Yes
No

Poor

Average

Good

Excellent

c. Personal financial
planning

Yes
No

Yes
No

Poor

Average

Good

Excellent

d. Transportation

Yes
No

Yes
No

Poor

Average

Good

Excellent

Yes
No

Yes
No

Poor

Average

Good

Excellent

e. Income support
VA Form
April 2011 10-10072a

4581649300

Did you need
this service?

Did you receive
this service?
Yes
No

f. Legal

Yes
No

g. Child care

Yes
No
Yes
No

Yes
No
Yes
No

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

h. Housing counseling

What was the quality of service?
Poor

Average

Good

Excellent

Poor

Average

Good

Excellent

Poor

Average

Good

Excellent

Poor

Average

Good

Excellent

Poor

Average

Good

Excellent

Poor

Average

Good

Excellent

Poor

Average

Good

Excellent

Poor

Average

Good

Excellent

Poor

Average

Good

Excellent

4. Other Supportive Services
a. Rental assistance
b. Utility fee payment
assistance
c. Security and utility
deposits
d. Moving costs
e. Purchase of
emergency supplies
f. Other:

Please answer questions 7 - 10B if you have recently begun receiving services from this provider. You do
not need to answer these questions if this is the second time you are completing this survey.
7. Have you ever lived in one of the following places?
Yes

No On the street or a place not meant for human habitation

Yes

No In your car, boat, or an abandoned building
No Emergency shelter or drop-in center

Yes
Yes
Yes
8.

No Transitional housing or halfway house
No Hotel/motel, Single Room Occupancy (SRO), Safe Haven

How many times did you move in the year before you requested help at this program?

0
1
2+
9. In the year before you requested help from this supportive services provider, was it sometimes hard to pay for housing due
Yes
No
to a change in income?
10. Did your employment status (employed full time, employed part time, unemployed) change significantly in the year before
you requested help from this supportive services provider?

Yes

No

Start Working
Stop Working
10A. If you answered Yes to Question 11, did you start working or stop working?
10B. If you answered No to Question 11, what is your employment status?
Employed full time Employed part time Unemployed

Please answer questions 11 - 13B if you are no longer receiving services from this provider or will no longer be
receiving services from this provider in the immediate future. You do not need to answer these questions if you
answered questions 8-10B.
11. How many times have you moved since you started receiving services from this provider?

0

1

2+

12. Since you started receiving services was there a time when your income
decreased so much that it became hard to pay your housing costs?
Yes

No
13. Has your employment status changed significantly (employed full time, employed part time, unemployed) since you
started receiving services from this supportive services provider?
Yes
No

13A.If you answered Yes to Question 13, did you start working or stop working?
13B. If you answered No to Question 11, what is your employment status?

Start Working

Employed full time

Stop Working

Employed part time

Unemployed

Thanks for your feedback. If you have any questions, please feel free to contact the SSVF Program Office at 1-877-737-0111 or via email at [email protected] or visit http://www.va.gov/homeless/ssvf.asp.

VA Form
April 2011 10-10072a

6422649306