Form Indiana WF 1.12.24 Indiana WF 1.12.24 Indiana WF 1.12.24

OMB Number: 2900-0876

Expiration: 2/28/2026

Estimated Burden: 2 minutes

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: Dial 988 (Press 1) or 1 (800) 273-8255 (Press 1), text 838255, or visit 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.

Your opinion matters. We care about your time with VA. Please take this survey to let us know about your experience. The more information you share with us, the better we can serve you.

This voluntary survey should take you approximately 2 minutes to complete.

1. Which VAMC do you usually go to for your medical needs?

1. Battle Creek, MI

2. Chicago, IL

3. Cincinnati, OH

4. Danville, IL

5. Dayton, OH

6. Fort Wayne, IN

7. Hines, IL

8. Indianapolis, IN

9. Lexington Cooper, KY

10. Louisville, KY

11. Marion, IL

12. Marion, IN

13. Community Care

14. Other _________

2. Which factors most influence your preference to visit this location? Please rank your top 3 in order of importance.

• Quality of medical care provided.

• Trust in the medical professionals at the facility

• Ability to see the same doctors or care teams I seen have in the past

• Availability of specialized services, programs or treatments

• Travel distance to facility location

• Cleanliness of the facility

• Ease of scheduling

• Wait times for appointments.

• Ease of navigating the VAMC facility

• Location was designated to me during the scheduling process

• Other __________

3. Please elaborate on the factors that played a role in your decision to choose this location.

• Free response

4. Our records indicate that your home zip code is [ZIP CODE]. Is this correct?

1. Yes

2. No

Logic: If answer is No, proceed to Question 5. If Answer is Yes, survey ends.

5. Please provide your 5-digita zip code so that we may update our records: ___________

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 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. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to [email protected]. VA will not disclose your personal information to third parties outside VA without your consent or when immediately responding to an expressed concern or need for immediate information or resources.