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pdfECCC
V1 DRAFT
09/17/20
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: 2 minutes
Help us serve you better.
We want to hear about your recent interaction. By indicating how much
you agree or disagree with the statements below, you directly help us
improve VA services.
This survey should take approximately 2 Minutes to complete.
I understood the information provided by the [contact center agent].
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
The [agent] took a reasonable amount of time to address my need.
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
The issue that I contacted [contact center] about on [date/today] was resolved.
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I am satisfied with the service I received from [contact center].
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I trust VA to fulfill our country's commitment to Veterans.
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 recent
interaction?
Please select from one of the following options.
Select your response
[ Logic ]
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?
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 [Logic proceed to Demographics page]
No [Logic skip Demographics page]
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA.1 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.2 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.3 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.
[Logic: 1). Required if CCR Open Text Box is included on survey. 2). Required if Service Recovery. 3). Required unless exception.]
Privacy Policy
ECCC
V1 DRAFT
09/17/20
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: 2 minutes
Help VA improve its services.
We are working to better understand our customers. The following
questions are voluntary. By providing your data, your responses can help
us improve VA care and services. Thank you for your participation.
Are you Hispanic or Latino?
Yes
No
How would you describe your race? Please select all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
How would you describe your gender?
Male
Female
Non-Binary/ Third Gender
Prefer not to say
Finish
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA.1 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.2 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.3 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.
[Logic: 1). Required if CCR Open Text Box is included on survey. 2). Required if Service Recovery. 3). Required unless exception.]
Privacy Policy
ECCC
V1 DRAFT
09/17/20
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: 2 minutes
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 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.1 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.2 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.3 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.
[Logic: 1). Required if CCR Open Text Box is included on survey. 2). Required if Service Recovery. 3). Required unless exception.]
Privacy Policy
| File Type | application/pdf |
| File Modified | 2020-09-17 |
| File Created | 2020-09-17 |