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pdfOutpatient Medicine (Survey Web Page)
Emergency
Working Draft, Pre-Decisional, Deliberative document - Internal VA Use Only
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) 273-8255 (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) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 3 minutes
Help us serve you better
We want to hear about your recent 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 3 minutes to complete.
Which of the following factors influenced your decision to seek emergency
medical care at ? Select all that apply. Required
The distance to was convenient.
The wait to see an outpatient provider was too long.
The outpatient clinic didn't have the specialty I needed.
I was worried about receiving bills if I went to a community ER.
I trust the VA to take care of me.
I had an emergency medical need.
When I arrived at the front desk of the , I was treated with
compassion and respect. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Once my clinical treatment began, the healthcare team
checked in with me regularly and kept me in the loop. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Once my clinical treatment began, the healthcare team
listened to my concerns and showed they cared. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
The healthcare team made it easy for me to understand
my discharge instructions. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
A plan for future outpatient appointments was clearly communicated to me
prior to discharge.
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Overall, the was comfortable and clean. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Overall, I feel my wait times were reasonable. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Overall, I was satisfied with the service during my visit. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Based on this ER visit, I trust the to
serve me in the future. 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 visit at ?
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 patient experience.
No, I do not want VA to contact me about my patient experience.
Finish
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 3 minutes 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 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 https://
www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private to the extent provided by law.
Privacy Policy
Emergency Medicine (Post-Survey Web Page)
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) 273-8255 (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) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 3 minutes
Thank you for choosing VA
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously improve your experience with VA
services.
Please visit VA.gov to explore benefits, resources, and information
at VA.
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 3 minutes 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 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 https://
www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private to the extent provided by law.
Privacy Policy
| File Type | application/pdf |
| File Modified | 2020-03-31 |
| File Created | 2020-03-31 |