Form 10-0507 Veterans Health Benefits Handbook Satisfaction Survey

U.S. Department of Veterans Affairs

OMB approval number: 2900-0773
Estimated Burden: 20 minutes

Veterans Health Administration

Veterans Health Benefits Handbook Questionnaire

Instructions
•

Use a pencil or black pen.

•

Please SHADE your answer box completely

•

Mark only one box for each question, unless it tells you to “mark all that apply”.

•

To maintain confidentiality, please do not include your name, address, claim number or
any other identifying information.

•

When you have completed the survey, please do not fold or staple, place it in the enclosed
postage-paid envelope and put it in the mail.

OMB Control Number: 2900-0773
Paperwork Reduction Act Statement
The Paperwork Reduction Act of 1995 (PRA) requires us to notify you that this information collection
is in accordance with the clearance requirements of section 3507 of the PRA. VA may not conduct,
sponsor, or require the respondent to respond to this collection of information unless it displays a
valid OMB Control Number. All responses for this collection are voluntary. Public reporting burden
for this collection of information is estimated to average 20 minutes per response, including the time
necessary for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. The information collected
is intended for the improvement of process. Failure to furnish the requested information will have no
adverse effect on any VA benefits to which you may be entitled.
The information you supply will be confidential and protected by the Privacy Act of 1974 (5 U. S.C.
522a) and the VA's confidentiality statute (38 U.S.C. 5701) as implemented by 38 CFR 1.526(a) and 38
CFR 1.57 (b). Disclosure of information involves release of statistical data and other non-identifying
data for the improvement of services within the VA health care processing system and associated
administrative purposes. If you have comments regarding this burden estimate or any aspects of
this collection of information, call 1-800-929-VETS for mailing information on where to send your
comments.

Veterans Health Benefits Handbook Questionnaire
Please rate the following questions on a scale of 1 to 5 with 5 being
best
Q1

Q2

Was the information in your Handbook easy to
read and understand?

Q4

1 - Very Dissatisfied .............................................

1 - Very Dissatisfied .............................................

2 - Dissatisfied .....................................................

2 - Dissatisfied .....................................................

3 - Neither Satisfied nor Dissatisfied ....................

3 - Neither Satisfied nor Dissatisfied ....................

4 - Satisfied .........................................................

4 - Satisfied .........................................................

5 - Very Satisfied .................................................

5 - Very Satisfied .................................................

How well did you like the overall layout and
presentation of the information (was it easy to
find what you were looking for?)

Q5

2 - Unlikely ...........................................................

2 - Dissatisfied .....................................................

3 - Neither Likely or Unlikely ................................

3 - Neither Satisfied nor Dissatisfied ....................

4 - Likely ..............................................................

4 - Satisfied .........................................................

5 - Very Likely ......................................................

5 - Very Satisfied .................................................
Was your personalized information accurate
(was your name, eligibility factors, preferred
facility and contact numbers correct)?

1 - Very Dissatisfied .............................................
2 - Dissatisfied .....................................................
3 - Neither Satisfied nor Dissatisfied ....................
4 - Satisfied .........................................................
5 - Very Satisfied .................................................

Was the Handbook useful or resourceful (will
you be using it again for information)?

1 - Very Unlikely ..................................................

1 - Very Dissatisfied .............................................

Q3

What is your overall satisfaction with your
Veterans Health Benefits Handbook?

Q6

Will the information in your Handbook increase
the likelihood for you to use Veteran Health
Administration Services?

1 - Very Unlikely ..................................................
2 - Unlikely ...........................................................
3 - Neither Likely or Unlikely ................................
4 - Likely ..............................................................
5 - Very Likely ......................................................

Please tell us how you feel about the following statement:
Q7

I trust VA to fulfill our country's commitment to
veterans.
Strongly agree.......................................................
Somewhat agree...................................................
Neither agree or Disagree.....................................
Somewhat disagree ..............................................
Strongly disagree ..................................................

Consider all your recent experiences with VA ( which may have
included healthcare, benefits programs, or memorial services).
Please tell us how you feel about the following statement:
Q8

Q9

I got the service I needed.

Q10 I felt like a valued customer.

Strongly agree.......................................................

Strongly agree.......................................................

Somewhat agree...................................................

Somewhat agree...................................................

Neither agree or Disagree.....................................

Neither agree or Disagree.....................................

Somewhat disagree ..............................................

Somewhat disagree ..............................................

Strongly disagree ..................................................

Strongly disagree ..................................................

It was easy to get what I needed.
Strongly agree.......................................................
Somewhat agree...................................................
Neither agree or Disagree.....................................
Somewhat disagree ..............................................
Strongly disagree ..................................................

Thank you for completing the survey