Form 10-0476 Michael E. Debakey Home Care Program

OMB Control Number: 2900-0770
Estimated Burden: 10 minutes

Department of Veterans Affairs Patient Satisfaction Survey

Michael E. DeBakey Home Care Program

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 10 minutes. 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 improvements in the quality of service delivery by helping to shape the direction and focus of specific programs and services. Disclosure of information involves release of statistical data and other non-identifying data for the improvement of services within the VA healthcare system and associated administrative purposes. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Hello. I am calling from the MEDVAMC Home Care Program. We are conducting a telephone patient satisfaction survey for the services you recently received from the home care team. We have several questions and items to be addressed, which should take no more than ten minutes of your time. Your feedback is needed and is very important to us. Thank you for your help and time.

I want to remind you that all information is strictly private. It will not affect your VA care.

Please indicate your response to the following questions regarding your home care services: (inform them of rating scale below)

1 =Strongly Disagree 2 =Disagree 3 =Not Certain 4 =Agree 5 =Strongly Agree N/A = Not Applicable

The home care program was explained to me	1 2 3 4 5 N/A
The information I received was easy to understand	1 2 3 4 5 N/A
The home care staff was polite and respectful	1 2 3 4 5 N/A
Home visits were made as scheduled or canceled with notice	1 2 3 4 5 N/A
I have trust and confidence in the home care team	1 2 3 4 5 N/A
When I questioned my care, I got answers I understood	1 2 3 4 5 N/A
My pain was addressed during the nurse’s visit	1 2 3 4 5 N/A
The nurse explained my medication usage to me	1 2 3 4 5 N/A
I know how to contact the home care team	1 2 3 4 5 N/A
The Home Care Staff did everything they could to control my pain	1 2 3 4 5 N/A
I am able to suggest ways to improve my safety	1 2 3 4 5 N/A
I am satisfied with the overall services/care provided by the home care team	1 2 3 4 5 N/A
I am satisfied with the services provided by:
Clerk	1 2 3 4 5 N/A
Home Oxygen Clinic	1 2 3 4 5 N/A
Home Respiratory Contractor (Ventilators, Oxygen)	1 2 3 4 5 N/A
Nurse	1 2 3 4 5 N/A
Occupational Therapist	1 2 3 4 5 N/A
Pharmacist	1 2 3 4 5 N/A
Physician	1 2 3 4 5 N/A
Psychologist	1 2 3 4 5 N/A
Social Worker	1 2 3 4 5 N/A
The Home Medical Equipment Contractor	1 2 3 4 5 N/A
The Kinesiotherapist (KT)	1 2 3 4 5 N/A
The Nurse Practitioner	1 2 3 4 5 N/A
The Nutritionist	1 2 3 4 5 N/A
The Physical Therapist (PT)	1 2 3 4 5 N/A
The Speech Therapist (ST)	1 2 3 4 5 N/A
Now think about your experiences with all the services provided by the Department of Veterans Affairs (which include healthcare, benefits programs, or memorial services). Please tell us how you feel about the following statements
“I got the service I needed.”	1 2 3 4 5 N/A
“It was easy to get the service I needed.”	1 2 3 4 5 N/A
“I felt like a valued customer.”	1 2 3 4 5 N/A
“I trust VA to fulfill our country’s commitment to veterans.”	1 2 3 4 5 N/A

Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VA Form 10-0476
November 2017