2900-0876-V5 Pharmacy in Person

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
2900-0770
Expiration: 09/30/2023
09/30/2020
Estimated Burden: 2 minutes

Help us serve you better
We want to hear about your recent experience with Atlanta VA Clinic
Pharmacy Services. 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 2 minutes to complete.

I found it easy to get my prescriptions at Atlanta VA Clinic Pharmacy. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

My wait time was reasonable. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

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 Atlanta VA Clinic. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

During my most recent VA health care experience, I felt respected and comfortable.
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

I trust Atlanta VA Clinic for my health care needs. 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(s) with Atlanta VA Clinic? Please select from one
of the following options. Required
Will not provide additional feedback



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.

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. 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 may utilize individual Veteran survey data from this
survey or other sources to ensure the final scores truly and accurately represent the experiences of Veterans. 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 2 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. 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

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: 09/30/2023
Estimated Burden: 1 minute

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 all that apply.
American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

 White

Finish

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 may utilize
individual Veteran survey data from this survey or other sources to ensure the final scores truly and accurately represent the experiences of
Veterans. 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 1 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 which you may currently be receiving. 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

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: 09/30/20233
Estimated Burden: 1 minute

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.

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 may utilize
individual Veteran survey data from this survey or other sources to ensure the final scores truly and accurately represent the experiences of
Veterans. 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 1 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 which you may currently be receiving. 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