Form 10-211011 Final Dental Survey

OMB Control Number: 2900-0770
Estimated Burden Avg.: 15 min.
Expiration Date: 05/31/2022

SURVEY OF VETERANS' SATISFACTION WITH THE
VA DENTAL INSURANCE PROGRAM
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 requires us to notify you that this information collected
is in accordance with the clearance requirements of section 3507 of this Act. The public reporting
burden for this collection of information is estimated to average 15 minutes per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. No person will be
penalized for failing to furnish this information if it does not display a currently valid OMB control
number. Your obligation to respond to this survey is voluntary and failure to furnish this information
will have no effect on any benefits you are 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.

VA Form 10-211011 JUN 2019

OMB No. 2900-0770
Exp. Date 05/31/2022
Estimated Burden Avg. 15 min.

SURVEY OF VETERANS' SATISFACTION WITH THE VA DENTAL INSURANCE PROGRAM
Q1

Who did you select as your dental provider?

Q7

Delta Dental.............................................................
MetLife ....................................................................

Q2

Q3

Excellent..................................................................
Very Good ...............................................................

How would you describe the area where you live?
Urban (greater than
1000 people per
square mile) ..............
Rural ( 8 to 999
people per square
mile) ..........................

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

Highly Rural (less
than 8 people per
square mile) ..............

Fair ..........................................................................
Poor.........................................................................

Q8

How reasonable was the distance you had to travel
to the dental provider?

Very Satisfied ..........................................................
Neither Satisfied Nor Dissatisfied ............................

Reasonable .............................................................

Fairly Dissatisfied ....................................................

Neither Reasonable Nor Unreasonable...................

Not Satisfied At All ...................................................

Fairly Reasonable ...................................................

Q4

Would you please provide your age?

How satisfied are you with the costs of the VA
Dental Insurance Program?
Highly Satisfied........................................................

Very Reasonable .....................................................

Not Reasonable At All..............................................

Considering premiums and out of pocket costs, how
would you describe the value of the VA Dental
Insurance Program?

Q9

Would you like to see your family included in the
program?
Yes ..........................................................................

Less Than 30...........................................................

No............................................................................

30 To 40 ..................................................................

N/A ..........................................................................

41 To 50 ..................................................................
51 To 60 ..................................................................
61 To 70 ..................................................................
Greater Than 70 ......................................................

Q10 Please rate your overall satisfaction with the VA
Dental Insurance Program.
Excellent..................................................................
Very Good ...............................................................

Q5

How satisfied are you with how well the Dental plan
met your dental needs?

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

Highly Satisfied........................................................

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

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

Very Satisfied ..........................................................
Neither Satisfied Nor Dissatisfied ............................
Fairly Dissatisfied ....................................................
Not Satisfied At All ...................................................

Q6

Would you recommend VA Dental Insurance
Program to another Veteran?
Yes ..........................................................................
No............................................................................

Page 1 of 2

Q11 If your rating is not excellent or very good, please
tell us why.

VA Form 10-211011 JUN 2019

Q12 Do you plan on renewing your coverage under the
VA Dental Insurance Program?
Yes ..........................................................................
No............................................................................

Page 2 of 2

OMB No. 2900-0770
Exp. Date 05/31/2022
Estimated Burden Avg. 15 min.

Q13 Please provide us any comments to improve the
Dental program.