VA Form 10-0463A Service Member/Veteran Primary Caregiver Satisfaction Su

Service Member/Veteran Primary Caregiver Satisfaction Survey

Federal Recovery Coordination Program

OMB 2900-0570

Respondent Burden: 15 minutes

1. What is your relationship to the Service Member/Veteran?

Spouse Parent Sibling Son/Daughter Significant Other

Friend Other Relative Other

2. In the past year, have you ever contacted your Service Member/Veteran’s Federal Recovery Coordinator for assistance or help?

Yes, go to question 3 No, go to question 7

I am not aware or do not know if my Service Member/Veteran has a Federal Recovery Coordinator. (Interviewer: Thank you and this ends the survey)

3. 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) _______________________________

4. What is the usual way you contact your Service Member/Veteran’s Federal Recovery Coordinator?

Phone call (go to question 5)

Email (go to question 6)

In person

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

5. How would you rate the response to your phone calls from your Service Member/Veteran’s Federal Recovery Coordinator?

Same Day

1 day

3 days

I leave messages and no one calls back

6. How would you rate the response to your emails from your Service Member/Veteran’s Federal Recovery Coordinator?

Same Day

Within 1 - 2 days

Within 3 - 4 days

I never receive a response

My Service Member/Veteran’s Federal Recovery Coordinator calls me back by phone

7. In the past 3 months, how frequently did your Service Member/Veteran’s 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 Service Member/Veteran’s FRC has not contacted me directly during the last 3 months

8. How would you rate your Service Member/Veteran’s Federal Recovery Coordinator’s personal manner (courtesy, respect, sensitivity, friendliness)?

Excellent

Very Good

Good

Fair

Poor

NA or don’t know

9. How satisfied are you with the ease of availability of your Service Member/Veteran’s Federal Recovery Coordinator?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

10. How would you rate your confidence in your Service Member/Veteran’s Federal Recovery Coordinator?

Excellent

Very Good

Good

Fair

Poor

11. How satisfied are you with your Service Member/Veteran’s Federal Recovery Coordinator’s ability to understand and respond to your needs and those of the SM/V?

Very Satisfied

Satisfied

Neither Satisfied or Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

12. How satisfied are you with the follow up by your Service Member/Veteran’s 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 Service Member/Veteran’s Federal Individual Recovery Plan.

13. My Service Member/Veteran has a Federal Individual Recovery Plan (FIRP).

Yes (go to question 14)

No (go to question 21)

Don’t know (go to question 21)

14. How often were you involved in the development and review of your Service Member/Veteran’s Federal Individual Recovery Plan?

Always

Usually

Sometimes

Never

Don’t know

15. How would you rate the attention given to what you had to say by your Service Member/Veteran’s Federal Recovery Coordinator in developing your goals?

Excellent

Very Good

Good

Fair

Poor

16. How satisfied are you with the goals reflected in the your Service Member/Veteran’s FIRP?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

17. How satisfied are you with the amount of information given to you about what was needed to achieve your Service Member/Veteran’s goals?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

18. How satisfied are you with knowing who is responsible for helping to reach each of your Service Member/Veteran’s goals?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

19. How satisfied are you knowing that your Service Member/Veteran’s FIRP will achieve their goals?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Don’t know

20. Do you have a copy of your Service Member/Veteran‘s Federal Individual Recovery Plan (FIRP)?

Yes

No

Don’t know

21. How would you rate the overall quality of care and services you have or are receiving from your Service Member/Veteran’s Federal Recovery Coordinator?

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

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

24. 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 10-0463A