Medical Foster Home (MFH) Program Caregiver Survey

Medical Foster Home Caregiver 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 00 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 Medical Foster Home services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

CAREGIVER Annual MFH Satisfaction Survey

The quality of the Medical Foster Home (MFH) program and services is very important to the Veteran, and to the VA MFH and home care team in supporting you as a MFH caregiver.  Therefore, your opinion is very important and we value your ongoing feedback.  Please take some time and honestly answer the following questions.  You can include your name at the top only if you wish, or be anonymous.  Either way, we value your feedback. This information will be used to help us identify our program’s strengths and areas we can improve.  Thank you for your time and your commitment to serve our MFH Veterans. Please circle your preferred reply.

Caregiver name (Optional) ________________________________________________________ Date: ________________

1. Circle your current age:

21-35 36-45 46-55 56-65 66-75 over 75

2. How long have you been a MFH caregiver?

1-6 mos 7-12 mos 1-2 yrs 2-3 yrs 3-4 yrs 4-5 yrs 5-6 yrs 6-7 yrs 7-8 yrs 8-9 yrs 9-10 yrs 10+ yrs

3. What medical training or certification have you completed?

CNA LPN LVN RN OT PT SW HIV cert. Dementia cert. Mental health cert. Other N/A

4. Do you currently maintain a state license, registration, or certification to operate your MFH?

Yes No

5. Do you presently have a mix of Veterans and non-Veterans in your MFH?

Veterans only Mix of Veterans and non-Veterans

Caregiver’s response to the following statements:

6. ‘The MFH program has been a valuable, positive program in which to participate.’

Strongly agree Agree Undecided Disagree Strongly disagree

7. ‘I have been pleased with the amount of support and responsiveness of the MFH Coordinator.’

Strongly agree Agree Undecided Disagree Strongly disagree

8. ‘I have been pleased with the support and availability of the MFH Recreation Therapist’

Strongly agree Agree Undecided Disagree Strongly disagree N/A

9. ‘I have been pleased with the support and availability of the MFH program support assistant’

Strongly agree Agree Undecided Disagree Strongly disagree N/A

10. ‘I have been pleased with the availability and support of the VA home care team (physician; nurse; dietician; rehab therapist, and social worker, etc.)’.

Strongly agree Agree Undecided Disagree Strongly disagree

11. ‘For all of my MFH Veterans, I am able to typically access both routine and planned respite, as well as urgent respite that may be unplanned’.

Strongly agree Agree Undecided Disagree Strongly disagree

12. ‘At the present time, I plan to remain a MFH caregiver for at least the following length of time’.

1-12 months 1-2 years 2-3 years 3-4 years 4-5 years 5+ years

13. Additional comments or recommendations:__________________________________________________________

___________________________________________________________________________________________________________

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