Form 10-396a Grantee Satisfaction Survey Form

OMB Control No. 2900-XXXX

Estimated burden: 20 minutes

Expiration Date: XX/XX/20XX

DEPARTMENT OF VETERANS AFFAIRS

Telehealth Grant Program (THGP)

Grantee Satisfaction Survey

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 20 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 10-396a) 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 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 survey data from this survey or other sources to ensure the final scores truly and accurately represent the experiences of Grantees. 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 and your organization are entitled.

INTRODUCTION

You are being asked to complete this optional survey on behalf of your organization because your organization has one or more federal awards funded by the Department of Veterans Affairs (VA).

Results will be kept confidential and reported only in a manner that does not identify information about an individual or an organization. Your responses will NOT affect your current award or your eligibility for, or receipt of, future services or funding.

Your cooperation is greatly appreciated and will help VA to provide more effective customer service and identify areas of improvement. The results will be used to improve the quality of VA services, supports and products.

Instructions

Please answer the survey questions based on the services and supports available to you from VA during the past 12 months.

IF YOU HAVE HAD ONLY ONE VA GRANT DURING THE PAST 12-MONTHS: Please answer the

survey questions based on this discretionary grant or cooperative agreement your organization received from VA.

IF YOU HAVE HAD MULTIPLE VA GRANTS DURING THE PAST 12-MONTHS: Please answer

the survey questions by selecting one of the discretionary grants or cooperative agreements your organization received from VA. Please select the grant that has CLOSED most recently or the grant that is CLOSEST to completion. If you have continuing grants, select one that is at the end of a competitive cycle.

Please confirm that the Telehealth Grant or cooperative agreement I am responding about is supported by the following VA Office:

☐Yes Office of Connected Care

☐No (Please specify)

The grant or cooperative agreement I am responding about was awarded year(s) ago.

• Less than One

• One (1)

• Two (2)

• Three (3)

• Four (4)

• Five (5)

• More than five

• I don’t know

Please complete this survey by xx/xx/xxxx.

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DEMOGRAPHIC QUESTIONS

Which of the following BEST describes your organization (please check 1)?

☐State government

☐Local government (city, town, county)

☐American Indian tribal government or tribal organization

☐Educational institution

☐Hospital

☐Non-profit organization

☐Large for-profit organization

☐Small for-profit organization (small business)

☐Other (please specify:

Which of the following BEST describes your geography (please check 1)?

☐Rural

☐Highly rural

☐Medically underserved
___________________________________________________________

Your current position is (please check 1):

☐Grants Administrator

☐Business Officer

☐Project Director

☐Principal Investigator

☐Other (please specify) ________________________________________

DIRECTIONS: Please indicate how satisfied you are with each of the following, using the scale provided. Please respond based on the past 12 months.

1. YOUR EXPERIENCE WITH YOUR VA FUNDING OPPORTUNITY ANNOUNCEMENTS (NOFOs) AND THE APPLICATION PROCESS. (Please mark an X in the option that best describes your satisfaction level for level for each row.)

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Clarity of language in the VA NOFO.
VA guidance and assistance in explaining what is required for completing the grant application.
Clarity of the information included in the NOFO about review criteria VA used to review the grant.
Time allotted for the grant application process.
Ease of the grant application process.
Ability to open web links in the NOFO Application Guide.
Overall experience with the VA grant application process.

2. YOUR EXPERIENCE WITH YOUR GRANTS MANAGEMENT SPECIALIST. (Please mark an X in the option that best describes your satisfaction level for each row.)

The Grants Management Specialist (GMS) is responsible for the day-to-day fiscal and business management of a portfolio of VA grants. These activities may include, but are not limited to, evaluating grant applications for administrative and financial content and compliance with statutes, regulations, and guidelines; negotiating awards; providing financial consultation and technical assistance to applicants and recipients, including interpretation of grants administration policies and financial provisions; and administering and closing out grants. The GMS is your first VA contact in matters relating to your Compliance Reports.

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Promptness of response(s) to your inquiries (by telephone or email) by Grants Management Specialist.
Assistance provided to you by Grants Management Specialist during the application process about grants management policies and procedures.
Assistance provided to you by Grants Management Specialist about grants management policies and procedures after receiving a funding award.
Timeliness of response by Grants Management Specialist to prior approval requests.
Timeliness of the grant close-out process.
Level of professionalism (e.g., courteousness, responsiveness, respectfulness) of Grants Management Specialist.
Overall performance of Grants Management Specialist.

3. YOUR EXPERIENCE WITH VA TECHNICAL ASSISTANCE (TA).
   DIRECTIONS: When rating each of the statements below, please consider all technical assistance (TA) and training that your grant received from ANY sources. (Please mark an X in the option that best describes your satisfaction level for each row.)

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Helpfulness of TA resource(s) and support(s) prior to applying for grant funding.
Adequacy of information provided during the pre-award phase.
Timeliness of TA your program received once you received grant funding.
Adequacy of TA resource(s) and support(s) to help your grant program succeed.
Helpfulness of TA resource(s) and support(s) after you received a funding award.
Helpfulness of information provided during the VA program integrity webinars.
Clarity of TA about the grant close-out process.
Helpfulness of TA about the grant close-out process.
Helpfulness of TA in completing the Compliance Forms.
Clarity of TA in completing the Compliance Forms.

4. YOUR EXPERIENCE WITH VA SITE VISITS.

(Please mark an X in the option that best describes your satisfaction level for each row.)

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Helpfulness of guidance VA provided to help you prepare for site visit(s).
Amount of time your program had to prepare for VA site visit(s).
Professionalism (e.g., courteousness, responsiveness, respectfulness) of the on-site review team(s).
Timeliness of receiving debriefing information (e.g., site visit report).
Usefulness of debriefing information (e.g., site visit report).

5. YOUR EXPERIENCE WITH THE VA WEBSITE.

(Please mark an X in the option that best describes your satisfaction level for each row.)

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Ease of navigating the VA website.
Usefulness of information available on the VA website about how to apply for a VA grant.
Accessibility of online grants management policies and procedures.

6. Based upon your interactions and experience with the HHS Payment Management System (PMS), please indicate how satisfied you are with each of the following: (Please mark an X in the option that best describes your satisfaction level for each row.)

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Helpfulness of advice and assistance received from PMS Representative(s).
Timeliness of PMS Representative(s) in resolving your issue(s) or concern(s).
Level of professionalism (e.g., courteousness, responsiveness, respectfulness) of PMS Representative(s)
Overall performance of PMS Representative(s).

7. Overall, how was your experience with VA’s services, supports and guidance for your grant program?

8. Please provide up to three (3) suggestions describing how VA can improve its grants processes, services, and supports for you.

(1)

(2)

(3)

9. Is there anything else you would like to tell us?

Thank you for your time!

We greatly value your feedback.