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pdfThe VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Help us serve you better
We want to hear about your recent healthcare visit.
By indicating how much you agree or disagree with the statements
below, you directly help us improve VA services.
This survey should take you approximately 1 minute to complete.
After I entered , I found it easy getting to my appointment. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
After I checked in for my appointment, I knew what to expect. Required
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
My provider listened carefully to me. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
My provider explained things in a way that I could understand. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
After my visit, I knew what I needed to do next. Required
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
I am satisfied with the service I received from . Required
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
I trust to fulfill our country’s commitment to Veterans. Required
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience applying for education benefits. Please
select from one of the following options. Required
Select your response
Use the text box below to provide details about your experience. Please do not
include any personally identifiable information, Social Security Number, Veteran ID, or
medical information.
0/400
Can VA contact you about your feedback? Required
Yes, VA can contact me about my experience.
No, I do not want VA to contact me about my experience.
Would you like to volunteer your demographic information to help VA better
serve you?
Yes
No
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. This
information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
We are working to better understand our customers. The following
questions are voluntary.
Are you Hispanic or Latino?
Yes
No
How would you describe your race? Select one or more.
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Finish
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Thank you for your choosing VA
The U.S. Department of Veterans Affairs uses these surveys to
collect your feedback in order to continuously to improve your
experience with VA services.
Please visit Vets.gov to explore benefits, resources, and information
at VA.
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the instructions
and complete this survey. The results of this survey will be used to inform opportunities for program improvement in the quality
of VA services. Participation in this survey is voluntary, and your decision not to respond will have no impact on VA benefits or
services to which you may currently be receiving. By filling out this survey, you are authorizing VA database access to retrieve
veteran contact information to follow up with you accordingly for purposes of service recovery, potential crisis, or to learn more
about feedback you have shared regarding your experience with VA. VA cannot conduct or sponsor a collection of information
unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is
not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Help us serve you better
We want to hear about your recent appointment at .
By indicating how much you agree or disagree with the statements
below, you directly help us improve VA services.
This survey should take you approximately 1 minute to complete.
It was easy to get my appointment. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I got my appointment on a date and time that worked for me. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
When scheduling my appointment, I was treated with courtesy and respect. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I am satisfied with the service I received from . Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I trust to fulfill our country’s commitment to Veterans. Required
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience applying for education benefits. Please
select from one of the following options. Required
Select your response
Use the text box below to provide details about your experience. Please do not
include any personally identifiable information, Social Security Number, Veteran ID, or
medical information.
0/400
Can VA contact you about your feedback? Required
Yes, VA can contact me about my experience.
No, I do not want VA to contact me about my experience.
Would you like to volunteer your demographic information to help VA better
serve you?
Yes
No
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. This
information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
We are working to better understand our customers. The following
questions are voluntary.
Are you Hispanic or Latino?
Yes
No
How would you describe your race? Select one or more.
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Finish
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Thank you for choosing VA
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously to improve your experience with
VA services.
Please visit Vets.gov to explore benefits, resources, and information at
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Help us serve you better
We want to hear about your recent experience with
pharmacy. By indicating how much you agree or disagree with the
statements below, you directly help us improve VA services.
This survey should take you approximately 1 minute to complete.
It was easy to get my prescriptions filled at Pharmacy. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
Agree
Strongly Agree
4
5
My wait time was reasonable. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
1
2
3
When I picked up my prescription(s), I was treated with courtesy and respect. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I am satisfied with the service I received from . Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I trust to fulfill our country’s commitment to Veterans. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience applying for education benefits. Please
select from one of the following options. Required
Select your response
Use the text box below to provide details about your experience. Please do not
include any personally identifiable information, Social Security Number, Veteran ID, or
medical information.
0/400
Can VA contact you about your feedback? Required
Yes, VA can contact me about my experience.
No, I do not want VA to contact me about my experience.
Would you like to volunteer your demographic information to help VA better
serve you?
Yes
No
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. This
information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
We are working to better understand our customers. The following
questions are voluntary.
Are you Hispanic or Latino?
Yes
No
How would you describe your race? Select one or more.
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Finish
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Thank you for choosing VA
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously to improve your experience with
VA services.
Please visit Vets.gov to explore benefits, resources, and information at
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Help us serve you better
We want to hear about your recent experience with mailorder
prescriptions. By indicating how much you agree or disagree with the
statements below, you directly help us improve VA services.
This survey should take you approximately 1 minute to complete.
It was easy to request my mailorder prescription(s). Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I felt comfortable requesting my mailorder prescription(s). Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I knew when to expect my prescription(s). Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
My prescription(s) arrived at my preferred address. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I am satisfied with the service I received from . Required
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
I trust to fulfill our country’s commitment to Veterans. Required
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience applying for education benefits. Please
select from one of the following options. Required
Select your response
Use the text box below to provide details about your experience. Please do not
include any personally identifiable information, Social Security Number, Veteran ID, or
medical information.
0/400
Can VA contact you about your feedback? Required
Yes, VA can contact me about my experience.
No, I do not want VA to contact me about my experience.
Would you like to volunteer your demographic information to help VA better
serve you?
Yes
No
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. This
information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
We are working to better understand our customers. The following
questions are voluntary.
Are you Hispanic or Latino?
Yes
No
How would you describe your race? Select one or more.
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Finish
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Thank you for choosing VA
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously to improve your experience
with VA services.
Please visit Vets.gov to explore benefits, resources, and information
at VA.
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Help us serve you better
We want to hear about your recent experience with
labs and imaging. By indicating how much you agree or disagree with
the statements below, you directly help us improve VA services.
This survey should take you approximately 1 minute to complete.
It was easy to find the location for my lab tests or imaging. Required
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
My lab tests or imaging were completed within a reasonable time frame. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
When I got my lab tests (blood draw, etc.) or imaging (Xray, MRI, CT scan)
done, I was treated with courtesy and respect. Required
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
I am satisfied with the service I received from . Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I trust to fulfill our country’s commitment to Veterans. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience applying for education benefits. Please
select from one of the following options. Required
Select your response
Use the text box below to provide details about your experience. Please do not
include any personally identifiable information, Social Security Number, Veteran ID, or
medical information.
0/400
Can VA contact you about your feedback? Required
Yes, VA can contact me about my experience.
No, I do not want VA to contact me about my experience.
Would you like to volunteer your demographic information to help VA better
serve you?
Yes
No
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. This
information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
We are working to better understand our customers. The following
questions are voluntary.
Are you Hispanic or Latino?
Yes
No
How would you describe your race? Select one or more.
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Finish
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 1
Thank you for choosing VA
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously to improve your experience
with VA services.
Please visit Vets.gov to explore benefits, resources, and information
at VA.
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of one minute to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |