Form VA Form 10-0463 VA Form 10-0463 Service Member/Veteran Satisfaction survey

Service Member/Veteran Satisfaction Survey

Federal Recovery Coordination Program

OMB 2900-0570

Respondent Burden: 15 minutes

1. In the past year, have you ever contacted your Federal Recovery Coordinator for assistance or help?

Yes, go to question 2 No, go to question 6

I am not aware or do not have a Federal Recovery Coordinator (Interviewer: ask to speak to the primary caregiver and administer that survey.)

2. What were the reasons for contacting your Federal Recovery Coordinator?

(Check all that apply)

1. Help with clinic appointments Yes No

a.1 If yes, which clinic_________________________

2. Help with getting a specific benefit Yes No

b.1 If yes, which benefit_________________________

3. Help getting into a rehabilitation center Yes No

c.1 If yes, was it military, VA, or Private Sector? Name________________

4. Help getting counseling services Yes No

d.1 If yes, which services? ___________________

5. To get more information Yes No

e.1 If yes, what kind of information? _______________________

6. Help with your primary case manager Yes No

f.1 If yes, what kind of help? ___________________

f.2 If yes, what facility is your case manager located? _______________

(i.e.; WRAMC, Richmond, Polytrauma, etc.)

g. Help with financial issues (including pay and disability or other compensation)

Yes No

h. Help getting medications

Yes No

i. Help getting military awards

Yes No

j. Other (please specify) _______________________________

3. What is the usual way you contact your Federal Recovery Coordinator?

Phone call (go to question 4)

Email (go to question 5)

In person

Other – please specify (mail, caregiver, etc) ________________

4. How would you rate the response to your phone calls from your Federal Recovery Coordinator?

Same Day

2 day

3 days

I leave messages and no one calls back

5. How would you rate the response to your emails from your Federal Recovery Coordinator?

Same Day

Within 1 - 2 days

Within 3 - 4 days

I never receive a response from my Federal Recovery Coordinator

My Federal Recovery Coordinator calls me back by phone

6. How would you rate your Federal Recovery Coordinator’s personal manner (courtesy, respect, sensitivity, friendliness)?

Excellent

Very Good

Good

Fair

Poor

NA or don’t know

7. In the past 3 months, how frequently did your Federal Recovery Coordinator initiate contact with you using any method: i.e. phone, email, or letter?

More than once a week

Once a week

Every 2 weeks

Once a month

My FRC has not contacted me directly during the last 3 months

8. How satisfied are you with the ease of availability of your Federal Recovery Coordinator?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

9. How would you rate your confidence in your Federal Recovery Coordinator?

Excellent

Very Good

Good

Fair

Poor

10. How satisfied are you with your Federal Recovery Coordinator’s ability to understand and respond to your needs?

Very Satisfied

Satisfied

Neither Satisfied or Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

11. How satisfied are you with the follow up by your Federal Recovery Coordinator after your initial contact?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

The next several questions ask about your Federal Individual Recovery Plan.

12. I have a Federal Individual Recovery Plan (FIRP).

Yes (go to question 13)

No (go to question 20)

Don’t know (go to question 20)

13. How often were you involved in the development and review of your Federal Individual Recovery Plan?

Always

Usually

Sometimes

Never

Don’t know

14. How would you rate the attention given to what you had to say by your Federal Recovery Coordinator in developing your goals?

Excellent

Very Good

Good

Fair

Poor

15. How satisfied are you with your goals reflected in the FIRP?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

16. How satisfied are you with the amount of information given to you about what was needed to achieve your goals?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

17. How satisfied are you with knowing who is responsible for helping you reach each of your goals?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

18. How satisfied are you knowing that your FIRP will achieve your goals?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

19. Do you have a copy of your Federal Individual Recovery Plan (FIRP)?

Yes

No

Don’t know

20. How would you rate the overall quality of care and services you have or are receiving from your Federal Recovery Coordinator?

     

21. What do you like best about the Federal Recovery Coordinator Program (FRCP)?

     

22. What do you least like about the Federal Recovery Coordinator Program (FRCP)?

     

23. Do you have any suggestions for improvement of the Federal Recovery Coordinator Program (FRCP)?

     

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 15 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. No person will be penalized for failing to furnish this information if it does not display a currently valid OMB control number. This collection of information is intended to fulfill the need identified by the Department of Veterans Affairs in their call for the development of needed improvements to the current VHA program. Response to this survey is voluntary and failure to furnish this information will have no effect on any of your benefits.

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VA Form 10-0463