Income Verification Process Survey

U.S. Department of Veterans Affairs

OMB approval number: 2900-0770
Estimated Burden: 6 minutes

Veterans Health Administration

SURVEY OF VETERANS' SATISFACTION WITH THE
INCOME VERIFICATION PROCESS SERVICE
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 it in the enclosed
postage-paid envelope and put it in the mail.

OMB Control Number: 2900-0770
Paperwork Reduction Act Statement
The Paperwork Reduction Act of 1995 (PRA) requires us to notify you that this information collection
is in accordance with the clearance requirements of section 3507 of the PRA. VA may not conduct,
sponsor, or require the respondent to respond to this collection of information unless it displays a
valid OMB Control Number. All responses for this collection are voluntary. Public reporting burden
for this collection of information is estimated to average 6 minutes per response, including the time
necessary for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. The information collected
is intended for the improvement of process. Failure to furnish the requested information will have no
adverse effect on any VA benefits to which you may be entitled.
The information you supply will be confidential and protected by the Privacy Act of 1974 (5 U. S.C.
522a) and the VA's confidentiality statute (38 U.S.C. 5701) as implemented by 38 CFR 1.526(a) and 38
CFR 1.57 (b). Disclosure of information involves release of statistical data and other non-identifying
data for the improvement of services within the VA health care processing system and associated
administrative purposes. If you have comments regarding this burden estimate or any aspects of
this collection of information, call 1-800-929-VETS for mailing information on where to send your
comments.

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 deductable 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

OMB: 2900-0770

Very Good.....

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

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

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