Community Living Centers (CLC) Survey-Updated trust question

Community Living Center Survey

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.

We want to hear about your experience with your Community Living Center. By responding

to this survey, you will directly help us improve the services we provide to CLC residents like

you. VA wants to provide you with the best possible living experiences!

This voluntary survey will take about 2 minutes to complete.

1. I feel like the staff really listen to me here.

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

2. If I have a problem, I feel comfortable speaking up.

   1. Strongly Disagree

   2. Disagree

   3. Neither Agree nor Disagree

   4. Agree

   5. Strongly Agree

3. This CLC feels home-like to me.

   1. Strongly Disagree

   2. Disagree

   3. Neither Agree nor Disagree

   4. Agree

   5. Strongly Agree

4. I’m getting good quality care here.

   1. Strongly Disagree

   2. Disagree

   3. Neither Agree nor Disagree

   4. Agree

   5. Strongly Agree

5. I trust VA CLC to take care of me. Required

   1. Strongly Disagree

   2. Disagree

   3. Neither Agree nor Disagree

   4. Agree

   5. Strongly Agree

6. CLC can contact me about my experience.

• Yes [Logic proceed to question #7]

• No [Logic proceed to question #8]

7. Please provide your last name and date of birth:

Last Name: Required [Logic: Display and make required if question #6 is yes]

Date of Birth: Required [Logic: Display and make required if question #6 is yes]

8. Would you like to volunteer your demographic information to help VA better serve you?

• Yes [Logic proceed to Demographics page]

• No [Logic skip Demographics page]

Next

Help VA improve its services.

We are working to better understand our customers. The following questions are voluntary. Your responses can help us improve VA care and services. Thank you for your participation.

9. What is your age?

• <30

• 30-39

• 40-49

• 50-59

• 60-69

• 70-79

• 80-89

• 90+

10. How would you describe your race? Please select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Middle Eastern or North African

11. Are you Hispanic or Latino?

• Yes

• No

12. How would you describe your gender? Please select all that apply.

• Male

• Female

• Transgender Man

• Transgender Woman

• Non-Binary/Third Gender

• Prefer not to say [Logic: when Prefer not to say is selected, no other option can be selected in the question]

• Other

Done

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.