Form VA Form 10-10065 VA Form 10-10065 Ethics Consultation Feedback Tool

OMB 2900-0750
Estimated Burden: 5 minutes

ETHICS CONSULTATION FEEDBACK TOOL
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, VA
may not conduct or sponsor, and you are not required to respond to a collection of information unless it displays a valid
OMB number. VA anticipates that the time expended by all individuals who complete this survey will average 5 minutes.
This includes the time it will take to read instructions, gather necessary facts and fill out the form. Customer satisfaction
surveys are used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of
this survey will lead to improvement in the quality of service delivery by helping to shape the direction and focus of specific
programs and services. Submission of this form is voluntary and failure to respond will have no impact on benefits to which
you may be entitled.
Recently, you spoke with someone from the Ethics Consultation Service. The job of the service is to help patients, families, and
staff work through ethical concerns by listening to what everyone thinks and helping people decide the best thing to do. In order
to help improve the Ethics Consultation Service, we ask that you take a few minutes to complete this form.
DIRECTIONS: For each of the following statements, please place an “X” in the box that best describes your most
recent experience with the Ethics Consultation Service. NOTE: NA = "Not Applicable"

Rate the Ethics Consultant(s) on:

Excellent

Very
Good

Good

Fair

Poor

Making you feel at ease
Respecting your opinions
Being an expert in ethics
Giving you useful information
Explaining things well
Clarifying decisions that had to be made
Clarifying who is the right person to make the
decision(s)
Describing possible options
Clearing up any disagreements
Being easy to get in touch with
Being timely enough to meet your needs
Providing a helpful service
Overall, my experience with the Ethics
Consultation Service was:
Did the consultation service make any recommendations?

Yes

No

Don't Know

If yes, were the recommendations generally followed?

Yes

No

Don't Know

Please write any comments or suggestions you may have for the Ethics Consultation Service in the space below:

VA Form 10-10065
MAY 2016

N/A

Don't Know