Form 2900-0876-AB1 Telemedicine Home Continuing Patient

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 htt(;1s://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 htt(;1s://www.va.gov/HOMELESS/.

0MB Number: 2900-0876
Expiration: 09/30/2023
Estimated Burden: 2 minutes

Help us serve you better
We want to hear about your current experience as someone who engages in
daily Home Telehealth monitoring 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.

If I take my vitals, submitting them each day (i.e., blood sugar, blood pressure, weight,
etc.) is a simple process. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

I know that when I submit my responses to questions and vitals, my Care Coordinator
will review them. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

I feel safe knowing that my Care Coordinator is monitoring my health. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

During phone calls, the care given by my Care Coordinator put me at ease.
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

I trust Home Telehealth program as part of my overall VA healthcare. Required

Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

Would you like to volunteer your demographic information to help VA better serve you?
Yes
No

If you provide feedback, you may be contacted by VA. Serving you is our top priority.

Next

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 0MB control number is displayed. You are not required to respond to a collection of information
if this number is not displayed. Valid 0MB control numbers can be located on the 0MB Internet Page at htt12s://www.reginfo.gov/12ublic/do/PRAMain.
Information gathered will be kept private to the extent provided by law.