Local Patient Satisfaction Survey Approval

LOCAL PATIENT SATISFACTION SURVEY
APPROVAL
1. FACILITY NAME

2. STATION

3. CONTACT NAME

4. CONTACT PHONE

5. CONTACT E-MAIL

6. SURVEY TITLE
7. IS THIS A PATIENT SATISFACTON SURVEY?

YES

NO

YES

NO

IF THE ANSWER IS NO THIS SURVEY WILL NOT BE APPROVED.

8. ARE ALL QUESTIONS FROM THE PRE-APPROVED LIST AT
http://vaww.oqp.med.va.gov/oqp_services/veterans_satisfaction/vss.asp ?
IF THE ANSWER IS NO THIS SURVEY WILL NOT BE APPROVED.

9. SURVEY WILL BE ADMINSTERED TO:

SPECIFIC CLINIC (PEASE SPECIFY):

10. WHAT SURVEY METHOD WILL BE USED?
11. IS THE OMB NUMBER AND PRA STATEMENT PRINTED ON ALL PRINTED SURVEYS?

YES

NO

IF THE ANSWER IS NO THIS SURVEY WILL NOT BE APPROVED.

12. HOW MANY PATIENTS WILL BE SURVEYED?

13. HOW OFTEN WILL PATIENTS BE SURVEYED?

14. VHA DIRECTIVE 2006-007 PROHIBITS PATEINTS FROM BEING SURVEYED MORE THAN ONCE
PER YEAR. ARE PROCEDURES IN PLACE TO ENSURE COMPLIANCE WITH THE DIRECTIVE?
YES

NO

15. HOW LONG WILL IT TAKE TO COMPLETE?

IF THE ANSWER IS NO THIS SURVEY WILL NOT BE APPROVED

Months

Days

16. COMPUTE THE BURDEN HOURS

(NO. OF RESPONDENTS x MINUTES TO COMPLETE DIVIDED BY 60.)

17. WILL PERSONALLY IDENTIFIABLE INFORMATION BE COLLECTED?

YES

NO

18. IF YES, WILL DATA BE STORED ON A SECURE, DIRECTIVE 6504 COMPLIANT VA SERVER?
YES

19. DESCRIBE HOW PATIENT PRIVACY WILL BE ENSURED

20. DESCRIBE THE DATA ANALYSIS PLAN

21. HOW WILL DATA BE USED TO IMPROVE LOCAL CARE

USE COMMENTING TOOLS TO ATTACH A COPY OF THE SURVEY HERE
VA FORM 10-0458
SEP 2006

NO