Form VA Form 10-21088 VA Form 10-21088 Survey of Veteran Enrollees - Quality and Efficiency of

OMB Number 2900-XXXX
Estimated burden: 10 minutes

SURVEY OF VETERAN ENROLLEES

QUALITY AND EFFICIENCY OF VA HEALTH CARE
The Paperwork Reduction Act of 1995 requires us to notify you that this information collected is in accordance with
the clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is
estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Response to this survey is voluntary and failure to furnish this information will have no effect on any of your applications
for benefits. This information is collected under the authority of Title 38, Part 1, Chapter 5, Section 527 and is intended
to fulfill the need identified by the the Department of Veterans Affairs.
This survey is designed to gather information from you that will help the Department of Veterans Affairs (VA)
give you the Physician Starter Set Performance Measure Report in a useful and meaningful way.

Providing information on this survey is voluntary and be assured that your survey answers are confidential.
1. I find the report easy to
understand.

3. I find the information provided by
the report to be useful.

Strongly Agree

Strongly Agree

Agree

Agree

Not Sure

Not Sure

Disagree

Disagree

Strongly Disagree

Strongly Disagree

2. I find the charts on the report
easy to understand.

4. I would like to continue to
receive the report.

Strongly Agree

Strongly Agree

Agree

Agree

Not Sure

Not Sure

Disagree

Disagree

Strongly Disagree

Strongly Disagree

Thank you for taking the time to complete this survey.
General Comments: Please use this space to share your comments on the report with us or to elaborate
on any of the responses you provided.

VA FORM
JUL 2008

10-21088