Form VA Form 10-0527 VA Form 10-0527 PVAMC Low Vision Patient Satisfaction Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

PVAMC Advanced Low Vision Clinic QA Survey

VHA Generic Request: Notice Nurse Comment Card; Low Vision Clinic Patient Satisfaction Survey; Vendor Registration; Telephone Transformation Focus Group

OMB: 2900-0770

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Portland VAMC
Advanced Low Vision Clinic Survey






VA Form 10-0527
Estimated Burden: 11 minutes


OMB 2900-XXXX







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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 11 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 or services. Completion of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.



Portland VAMC Advanced Low Vision Clinic

Patient Satisfaction Survey


We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept private and anonymous. Thank you for your time.


Your Age: _______ Your Race/Ethnicity: ___ White

___ Black or African American

Your Sex: ___ Asian

Male ____ ___ American Indian or Alaska native ___ Native Hawaiian or other Pacific Islander

Hispanic or Latino yes___ no___

Female ____






PShape2 lease circle how well you think we are doing in the following areas:

GREAT
5

GOOD
4

OK
3

FAIR
2

POOR
1

EXAMPLE of how to properly circle your answer:

5Shape3

4

3

2

1

Ease of getting care:






Ability to get in to be seen

5

4

3

2

1

Hours Center is open

5

4

3

2

1

Convenience of Center’s location

5

4

3

2

1

Prompt return on calls

5

4

3

2

1

Waiting:






Time in waiting room

5

4

3

2

1

Time in exam room

5

4

3

2

1

Staff:






Provider: Low Vision Optometrist






Listens to me

5

4

3

2

1

Takes enough time with me

5

4

3

2

1

Explains what I want to know

5

4

3

2

1

Gives me good advice and treatment

5

4

3

2

1

Low Vision Therapist ,Orientation and Mobility Specialist






Friendly and helpful to me

5

4

3

2

1

Answers my questions

5

4

3

2

1








Please circle how well you think we are doing in the following areas:

GREAT
5

GOOD
4

OK
3

FAIR
2

POOR
1

Program Support Assistant:






Friendly and helpful to me

5

4

3

2

1

Answers my questions

5

4

3

2

1

Additional Training and Receipt of Devices:






Devices/glasses received within a reasonable time frame

5

4

3

2

1

Education re: use and care of devices + factors affecting vision

5

4

3

2

1

Education about my eye condition

5

4

3

2

1

Facility:






Neat and clean building

5

4

3

2

1

Ease of finding where to go

5

4

3

2

1

Comfort and Safety while waiting

5

4

3

2

1

Privacy

5

4

3

2

1

Personal Privacy:






Keeping my personal information private to the extent of the law

5

4

3

2

1

The likelihood of referring other Veterans to us

5

4

3

2

1



What do you like best about our Low Vision Program? ______________________________________________________________________________


______________________________________________________________________________


What do you like least about our Low Vision Program?


______________________________________________________________________________


______________________________________________________________________________


Suggestions for improvement? ___________________________________________________


______________________________________________________________________________


______________________________________________________________________________


Thank you for completing our Survey!




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VA Form 10-0527
OCT 2011

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleTHE QUALITY CENTER
AuthorBarbara Braden
File Modified0000-00-00
File Created2021-01-31
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