Care Coordination Home Telehealth Patient Satisfaction Survey

OMB 2900-XXXX
Estimated Burden 1.5 min.

Care Coordination Home Telehealth (CCHT)
Patient Satisfaction Survey
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
1.5 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 current 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 evaluation and improvements to the current Patient Satisfaction program. Your obligation to
respond to this survey is voluntary and failure to furnish this information will have no effect on any of your benefits.

1. My care coordinator explains things in a way that is easy to understand.
Always
Usually
Sometimes
Never
2. The information provided by my care coordinator has helped me manage
my health problem(s).
Strongly Agree
Agree
Disagree
Strongly Disagree
3. Over the past 3 months, my home telehealth equipment works:
Always
Usually
Sometimes
Never
4. My home telehealth equipment is easy to use.
Strongly Agree
Agree
Disagree
Strongly Disagree

VA Form 10-0481
December 2009

5. I have made changes in the way I take care of myself as a result of the VA home
telehealth program.
Strongly Agree
Agree
Disagree
Strongly Disagree
6. When I have questions, I am able to contact my care coordinator during business hours.
Always
Usually
Sometimes
Never
7. Using the VA home telehealth program has made a positive difference in my health.
Strongly Agree
Agree
Disagree
Strongly Disagree
8. I would recommend a home telehealth program to others.
Strongly Agree
Agree
Disagree
Strongly Disagree

VA Form 10-0481
December 2009