Income Verification Survey

VHA Income Verification Survey
OMB No. 2900-0770
Estimated Burden: 6 minutes
Expiration Date: 9/30/2020

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 6 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 of VA services. Participation in this survey is voluntary and failure to respond
will have no impact on benefits to which you may be entitled.

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 in the enclosed postage paid
envelope and put it in the mail.

1

This questionnaire will help the Health Eligibility Center improve it's Income
Verification process.
Letters/Mailings
Q1

We send several letters to Veterans during the Income Verification Process. Please rate the following
statements on a scale of 1 to 5 with 5 being completely agree.
1 (not at all)

2

3

4

5 (completely)

I understood the letters completely
The wording was clear and
understandable
The instructions were easy to understand

Contacts with Staff
Q2

If you contacted the Income Verification Staff, please rate the following statements on a scale of 1 to 5
with 5 being completely agree.
1 (not at all)

2

3

4

5 (completely)

I felt the staff cared about my concerns
I was treated with dignity and respect
The answers provided were clear and
understandable

Q3

If you contacted our office, what was the reason(s)? (mark all that apply)
Did not u
nderstan
d the
letters .....

Check
the status
of mail
sent ........

Provide
additional
informati
on ...........

Complain
about the
process...

File
Notice of
Disagree
ment .......

Other,
enter in
comment
s .............

Income Verification Process
Q4

Please rate your understanding of the Income Verification process.
Completely....

Q5

Mostly ...........

Somewhat.....

Only a little....

Not at all .......

Which areas would you like to see us improve? (please select your two most important)
The waiver and hardship process
What are valid dependents
What income counts and what does not
What is deduct able and how do I find the
correct documents to mail in

Q6

All things considered. please rate your overall satisfaction with the Income Verification process.
Excellent .......

Q7

Comments

Very Good.....

Good.............

Fair ...............

Poor ..............