HEC Enrollment Survey

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Department of Veterans Affairs Health Care Enrollment Survey
Considering your experience from the time you filled out the VHA health benefits application
form to the time you received your enrollment decision, please answer the following questions
Q1

Why did you choose to apply for VA health benefits? (choose all that apply)
To use VA as my primary health care provider ............................................................................................................
To use VA for treatment of certain conditions and to coordinate care with my non-VA providers.................................
To satisfy my requirement to have health insurance coverage under the Affordable Care Act ...................................
Primarily to receive prescription drugs from VA ...........................................................................................................
To obtain a Veteran Identification Card........................................................................................................................
Other reasons

Q2

Please select your age group
30 or less.....................................................................................................................................................................
31 to 40 .......................................................................................................................................................................
41 to 60 .......................................................................................................................................................................
61 to 70 .......................................................................................................................................................................
Greater than 70 ...........................................................................................................................................................

Q3
Please select how you applied for VA health benefits?
Internet (go to Q4) ......................................................................................................................................................
In person with VHA staff (go to Q5) ............................................................................................................................
By mail (if so please skip to Q6)................................................................................................................................
Over the telephone (go to Q7) ....................................................................................................................................

VA Form 10-211013

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Please SHADE your answer selection

Q4

Please answer the following question concerning your Internet application experience. (After answering
this question please go to Q8.)
Strongly
Agree

Agree

Neither agree
nor disagree

Disagree

Strongly
disagree

The website was easy to navigate
The website response time was acceptable
The wording was clear and understandable
The instructions were easy to understand
The presentation of the benefits application
form was logical
I am confident my personal information is
secure
After submitting my information, I
understood the next steps in the enrollment
process
Please list any problems or Improvements needed

Q5

Please answer the following questions concerning your in person application experience. (After
answering this question please go to Q8.)
Strongly
Agree

Agree

Neither agree
or disagree

Disagree

Strongly
disagree

The staff was available to assist me with
filling out the application form
The staff was knowledgeable
The staff was courteous
The staff treated me with dignity and
respect
The location was convenient for me
After submitting my information, I
understood the next steps in the enrollment
process
Please list any problems or Improvements needed

Q6

Please answer the following questions concerning your mail in application experience. (After answering
this question please go to Q8.)
Strongly
agree

Agree

It was easy to obtain a blank application
form
The instructions were easy to understand
The wording was understandable
I received a timely response concerning my
application
After submitting my information, I
understood the next steps in the enrollment
process
Please list any problems or Improvements needed

VA Form 10-211013

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Neither agree
nor disagree

Disagree

Strongly
disagree

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Q7

Please answer the following questions concerning your telephone application experience.
Strongly
Agree

Agree

Neither agree
or disagree

Disagree

Strongly
disagree

The staff was available to assist me with
filling out the application form
The staff was knowledgeable
The staff was courteous
The staff treated me with dignity and
respect
After submitting my information, I
understood the next steps in the enrollment
process
Please list any problems or Improvements needed

Q8

How long did it take to complete the VA health benefits application?
Less than 15 minutes ..................................................................................................................................................
Less than 30 minutes ..................................................................................................................................................
Less than 45 minutes ..................................................................................................................................................
One hour or more ........................................................................................................................................................

Q9

If you were not able to complete the application form in one sitting, please tell us why.

Q10

From the time you submitted the health benefits application form, how long did it take to get your
enrollment decision?
1 week or less .............................................................................................................................................................
2 weeks .......................................................................................................................................................................
3 weeks .......................................................................................................................................................................
4 weeks .......................................................................................................................................................................
5 weeks .......................................................................................................................................................................
6 weeks or more ..........................................................................................................................................................
Have not received my Enrollment Decision ................................................................................................................

Q11

If you have not received your enrollment decision, how long has it been since you applied?
1 week or less .............................................................................................................................................................
2 weeks .......................................................................................................................................................................
3 weeks .......................................................................................................................................................................
4 weeks .......................................................................................................................................................................
5 weeks .......................................................................................................................................................................
6 weeks or more ..........................................................................................................................................................
N/A ..............................................................................................................................................................................

VA Form 10-211013

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Please SHADE your answer selection

Q12

How would you describe your overall experience with VA's health care enrollment process?
Extremely Satisfied......................................................................................................................................................
Very Satisfied ..............................................................................................................................................................
Satisfied......................................................................................................................................................................
Somewhat Satisfied.....................................................................................................................................................
Not Satisfied at all.......................................................................................................................................................

Q13

If you were not at least Very satisfied with the Enrollment process, please tell us why.
The application was not easy to complete ...................................................................................................................
It took too long to get my enrollment decision..............................................................................................................
VA staff were not helpful ..............................................................................................................................................
It took to long to get help filling out the application form ..............................................................................................
The on line process was confusing..............................................................................................................................
I was told I am not eligible for enrollment ....................................................................................................................
Other reasons

Q14

Please tell us how we can improve the VA's health care enrollment process.

Thank you for completing the survey

VA Form 10-211013

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