Form VA Form 10-0481a VA Form 10-0481a Clinical Video Telehealth (CVT) Patient Satisfaction Sur

OMB 2900-XXXX
Estimated Burden 3 minutes

Clinical Video Telehealth Patient Satisfaction Survey

Dear Veteran Patient,

It is important that we know what you think about the value of our Clinical Video Telehealth service program. Your comments will help us learn how we can improve care to all Veterans. We would greatly appreciate your taking a few minutes to complete the following survey.

First, we’d like you to know:

• The information that you provide will be kept private to the extent permitted by law. They will be reviewed by training center staff, not any local personnel.

• When you finish, please put the survey in the stamped envelope and give it to the clerk
  to mail. Local staff will not see your responses.

• Your comments will be combined with comments from other Veteran patients for improvement of services programs within this clinic.

Thank you for your time.

Department of Veterans Affairs

Clinical Video Telehealth (CVT) Satisfaction Survey

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, and completing and reviewing the collection of information. No person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. 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 improvements in the quality of service delivery by helping to shape the direction and focus of specific, programs and services. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

F acility or Site number : _________ Your Age: _______ Your Gender: Male Female

D ate Completed: ­­­­­___________ Was this your first Telehealth session? Yes No

T his Telehealth session was: Individual Group

S pecialty Clinic (please check one of the following)

T elePrimary Care TeleMental Health TeleNeurology

T eleRehabilitation TelePolytrauma TeleSCI TeleAudiology

T eleSpeech Pathology TeleSurgery TeleNutrition

T eleDiabetes TeleMove Telepharmacy

O ther _________________

Completed by: Patient Clerk Other (who?) ______________________________

We want to know what you thought about today’s telehealth session. Your honest answers will help us improve the system.
Please circle the number that is closest to your own opinion for each of the following statements.

STRONGLY DO NOT AGREE or STRONGLY
DISAGREE DISAGREE or N/A AGREE

Example: I felt well when I woke up this morning.	1		2		3		4		5
I felt comfortable with the equipment used.	1	2		3		4		5
I was able to see the clinician clearly.	1	2		3		4		5
I was able to hear the clinician clearly.	1	2		3		4		5
There was enough technical assistance for my meeting with the clinician.	1	2		3		4		5
My relationship with the clinician was the same during this session as it is in person.	1	2		3		4		5
The location of the telehealth clinic is convenient for me.	1	2		3		4		5
My needs were met during the session.	1	2		3		4		5
I received good care during the session.	1	2		3		4		5
The telehealth clinic provided the care I expected.	1	2		3		4		5
Overall, I am satisfied with this telehealth session.	1	2		3		4		5
I would recommend this type of session to other veterans.	1	2		3		4		5
I would rather use telehealth to receive this service than travel long distance to see my provider.	1	2		3		4		5

Please list any additional comments:

VA Form 10-0481a
June 2011