Community Residential Care (CRC) Program Veteran Survey

Community Residential Care Veteran Survey

OMB No. 2900-0770
Estimated Burden: 5 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 5 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 by helping to achieve Community Residential Care services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Annual Community Residential Care Veteran Survey

1. Veteran’s age: 21-35 36-45 46-55 56-65 66-75 76-85 86-95 95+

2. Length of time in CRC:

1-6 mos 7-12 mos 1-2 yrs 3-4 yrs 5-6 yrs 7-8 yrs 9-10 yrs 11-15 yrs 16-20 yrs 21+ yrs

3. “I feel safe in my CRC home”.

Strongly agree Agree Neutral Disagree Strongly disagree

4. “I am treated with dignity and respect by the CRC staff”.

Strongly agree Agree Neutral Disagree Strongly disagree

5. "The meals at my CRC home are nutritious and appealing to me".

Strongly agree Agree Neutral Disagree Strongly disagree

6. "My CRC home is clean".

Strongly agree Agree Neutral Disagree Strongly disagree

7. "I feel respected by the VA social worker and other VA staff".

Strongly agree Agree Neutral Disagree Strongly disagree

8. "The VA staff is available to me when I have concerns that require their attention".

Strongly agree Agree Neutral Disagree Strongly disagree

9. "The CRC staff is easily available to help me solve problems".

Strongly agree Agree Neutral Disagree Strongly disagree

10. "I am pleased with the offerings of recreational activities at my CRC home".

Strongly agree Agree Neutral Disagree Strongly disagree

11. “I am pleased with my CRC home keeping track of my appointments".

Strongly agree Agree Neutral Disagree Strongly disagree

12. "I am pleased with my CRC home arranging transportation when I need it".

Strongly agree Agree Neutral Disagree Strongly disagree

13. “I am pleased with my CRC home providing me medications as their scheduled".

Strongly agree Agree Neutral Disagree Strongly disagree

14. "I am pleased overall with my CRC home, and have no plans to leave at this time".

Strongly agree Agree Neutral Disagree Strongly disagree

15. "What I like best about my CRC home is..____________________________________________________

16. "If there is anything I could change at my CRC home, or within the CRC program, what would it be?" _________________________________________________________________________________________

17. Final comments _____________________________________________________________________________