Vet Apptmnt Apps Satisfaction Srvy/Hem-Oncology Telehealth Satisfaction Svy

OMB 2900-0770
Estimated Burden: 5 min.

TELEMEDICINE HEM/ONCOLOGY SERVICES SATISFACTION SURVEY

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Customer satisfaction surveys are used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this survey will lead to improvements in the quality of service delivery by helping to shape the direction and focus of specific programs and services. Disclosure of information involves release of statistical data and other non-identifying data for the improvement of services within the VA healthcare system and associated administrative purposes. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

S hade circles like this:	Strongly Agree	Agree	No Option	Disagree	Strongly Disagree
The following statements refer to the health care you received on today’s visit.
1. The clinic provided me with the care I expected:
2. Information given to me today about my health was clear and adequate:
3. The provider gave me opportunities to ask questions:
4. The provider explained the test results in a way I could understand:
The following statements refer to the access and convenience of the clinic services.
5. The location of the clinic is convenient for me:
6. Scheduling an appointment is an easy process:
7. The Telehealth clinic meets my needs and expectations as well as a face-to-face visit:
8. The Telehealth program is more convenient for me and my family compared to a face-to-face appointment at the Minneapolis facility.
9. Compared to a face-to-face visit at the Minneapolis facility, has the amount of time spent away from work for either yourself or family members decreased with utilization of the Telehealth program?	No	Y es	If yes, how many miles? ___________
10. How would you rate your overall satisfaction with the visit?	P oor	Fair	Good	Very Good	E xcellent

VA Form
MAR 2013

10-10054