Form ECCC Member Servic ECCC Member Servic ECCC Member Services Wireframe

OMB Number: 2900-0876

Expiration: 2/28/2026

Estimated Burden: 4 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 recent interaction with the Health Resources Center. By indicating how much you agree or disagree with the statements below, you directly help us improve VA services.

This voluntary survey should take you approximately 4 minutes to complete.

1. I waited a reasonable amount of time to speak to an agent.

Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree

2. The agent took a reasonable amount of time to address my need.

Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree

3. I understood the information provided by the agent.

Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree

4. The agent I interacted with was helpful.

Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree

5. The issue that I contacted the Health Resources Center about on [Logic: Piped in Date] was resolved.

Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree

6. I am satisfied with the service I received from the Health Resources Center.

Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree

7. I trust VA to fulfill our country's commitment to Veterans.

Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree

8. Would you like to provide additional feedback with a concern, compliment, or

recommendation about your interaction with the Health Resources Center?

Please select from one of the following options.

1. Concern

2. Compliment

3. Recommendation

9. Use the text box below to provide details about your experience. Please do not

include any personally identifiable information, Social Security Number, Veteran

ID, or medical information.

[Text Box]

10. Can VA contact you about your feedback?

1. Yes, VA can contact me about my experience.

2. No, I do not want VA to contact me about my experience.

11. Would you like to volunteer your demographic information to help VA better

serve you? [Logic: End survey here if “No” is selected]

1. Yes

2. No

12. Are you Hispanic or Latino?

1. Yes

2. No

13. Would you describe your race? Please select all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black of African American

4. Native Hawaiian or Other Pacific Islander

5. White

14. How would you describe your gender?

1. Male

2. Female

3. Non-Binary / Third Gender

4. Prefer not to say.

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 4 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.