Form 10-317c SSG Fox SPGP - Participant Satisfaction Survey

OMB Control Number: 2900-XXXX

Estimated Burden: 15 minutes

Expiration Date: 04/30/2022

DEPARTMENT OF VETERANS AFFAIRS

Staff Sergeant Parker Gordon Fox Suicide Prevention Service Program (SSG Fox SPGP)

PARTICIPANT SATISFACTION SURVEY

The VA is seeking feedback regarding your experience with the Staff Sergeant Parker Gordon Fox Suicide Prevention Service Program (SSG Fox SPGP). Please take a few minutes to complete this survey – and do not reference information specific to you (such as any Personally Identifiable or Protected Health Information).

Paperwork Reduction Act of 1995 and Privacy Act Statement:

We are required to notify you that this information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 15 minutes. Any information provided is anonymous and will be kept private to the extent provided by law. Participation in this survey is voluntary, and failure to respond will have no impact on benefits to which a participant may be entitled.

Customer satisfaction is used to gauge customer perceptions of VA services, as well as customer expectations and desires. The results of this survey will lead to improvements in the quality-of-service delivery by helping to shape the direction and focus of services and the patient experience. Thank you for your participation.

If you have questions about the survey or the estimated burden, please contact the SSG Fox SPGP Team via e-mail at [email protected] or via phone at 1 202-502-0002

Number of individuals (including yourself) in household receiving suicide prevention services from this provider:

1 2 3 4+

Are you enrolled in the VA health care system?

Yes No

Were you enrolled in VA health care system prior to receiving services from this provider?

Yes No

1. How would you rate the quality of the services you have received from this SSG FOX SPGP Agency?

Extremely Poor Below Average Average Above Average Excellent

2. Did the SSG FOX SPGP Agency involve you in creating your service plan?

Yes No

2A. If you answered Yes to Question 2, do you feel that your service plan is a good fit for your needs?

Yes No

3. In the following section please select which suicide prevention services you received and indicate the quality of the services received.

Suicide Prevention Services	Did you need this service?	Did you receive this service?	What was the quality of service?
1. Case Management	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
2. Peer Support Services	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
3 Assistance in obtaining VA Benefits	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
4. Assistance in obtaining and coordinating other public benefits
a. Health care	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
b. Daily living	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
c. Personal financial planning	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
d. Transportation	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
e. Income support	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
f. Legal	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
g. Childcare	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
5. Other Supportive Services
Please choose services from list below*	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent

*A list of approved Nontraditional and Innovative and Evidence Informed approaches and practices will be available to choose from.

4. How helpful was the staff person that you first spoke with when you contacted this SSG FOX SPGP Agency? (very helpful, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied)

5. How helpful was the staff person that you dealt with most often while you were working with this SSG FOX SPGP Agency? (very helpful, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied)

6. How satisfied are you with how quickly and how often the SSG FOX SPGP Agency dealt with your needs? (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied)

7. How easy or simple was it to reach a person at the SSG FOX SPGP agency for the first time?

7A. If not easy, then why?

8. Please tell us your positive experiences with this SSG FOX SPGP Agency, and please tell us why.

9. Please tell us your negative experiences with this SSG FOX SPGP Agency, and please tell us why.

Please list any additional suggestions as to how to improve the SSG FOX SPGP Program for other Veterans.

VA Form 10-317c 11MHSP