Form VA Form 10-0479 VA Form 10-0479 Health Eligibility Center (HEC) New Enrollee Survey

OMB 2900-XXXX
Estimated Burden: 5.7 minutes

HEALTH ELIGIBILTY CENTER (HEC)

NEW ENROLLEE SURVEY

This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or
sponsor, and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who complete this survey will average 5.7 minutes. This includes the time it will take to read instructions, gather the
necessary facts and fill out the form. Customer satisfaction surveys are used to gauge customer perceptions of VA services as well as customer
expectations and desires. The results of this survey will lead to improvement in the quality of service delivery by helping to shape the direction
and focus of specific programs and services. Disclosure of information involves release of statistical data and other non-identifying data for the
improvement of services within the VA healthcare system and associated administrative purposes. Submission of this form is voluntary and
failure to respond will have no impact on benefits to which you may be entitled.

1) How did you apply for VA Health Care Benefits?
a. Internet

d. Over the telephone

b. In person at VA medical facility

e. Other

c. By mail
2) How easy was it to fill out the Application for Health Benefits?
(VA form 1010EZ or 1010EZR)
a. Very Easy

d. Somewhat difficult

b. Easy

e. Difficult

c. Neither easy or difficult
3) How long did it take to fill out the application form?
a. Less than 15 minutes

c. Less than 45 minutes

b. Less than 30 minutes

d. One hour or more

4) How long did it take to get your Enrollment Decision Letter?
a. 2 weeks or less

d. 6 weeks or more

b. 3 weeks

e. Have not received my
Enrollment Decision Letter

c. 4 weeks

5) How would you describe your overall experience with the VA Healthcare
Enrollment Process?
a. Highly Satisfied
b. Satisfied
c. Not Satisfied
6) If you enrolled under the Expanded Enrollment for Priority Group 8 Veterans,
how did you hear about the expanded benefits? (Check all that apply)
a. Doctor or HealthCare Professional

f. Veteran Service Organization

b. Another Veteran

g. VA Internet

c. Friend or Family member

h. Letter from the VA

d. VA Staff member

i. Do not recall

e. Flyer, brochure or newsletter

j. Other

VA Form 10-0479
October 2009