Form 10-396 Veteran Satisfaction Survey

OMB Control Number: 2900-XXXX

Estimated burden: 5 minutes

Expiration Date: XX/XX/20XX

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 988 (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/.

Help us serve you better.

We want to hear about your Telehealth Access Point experience. 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 5 minutes to complete.

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

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

I found it easy to schedule my Telehealth Access Point appointment. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

Connecting to my video appointment was easy. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

When connecting to my appointment, I felt confident using the technology provided. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

During my appointment, my provider made me feel at ease by explaining every step they took and in a way that was easy to understand. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

After my appointment, I was clear about my next steps of care. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

This Telehealth Access Point reduces the need to travel long distances in order to meet with my provider. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

I was able to see the provider clearly by video. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

I was able to hear the provider clearly by video. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

At the beginning of the video visit, the provider addressed privacy concerns. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

I would recommend this Telehealth Access Point to other Veterans. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

Overall, I am satisfied with the video telehealth visit. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

I felt the space provided at this Telehealth Access Point gave me privacy. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

I would recommend this Telehealth Access Point location as a place for VA care to a fellow Veteran. Required

1 Strongly Disagree

2 Disagree

3 Agree

4 Neither Agree nor Disagree

5 Strongly Agree

When you consider your options for the Telehealth Access Point appointment you just had, which do you prefer? Required

• 

Video visit

• 

Phone visit

• 

In-person visit

VA Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 2900-XXXX, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-XXXX in any correspondence. Do not send your completed survey (VA Form 10-396) to this email address.

Privacy Act Statement: Information gathered will be kept private to the extent provided by law. 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. 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 to which you are entitled.  

Privacy Policy

VA Form 10-396