Form VA Form 10-0549 VA Form 10-0549 Rx Label Feedback

Feedback Form
New VA Prescription Label
Dear Veteran,
Thank you for providing feedback on the new VA prescription label. We value your opinion. Please do not identify
yourself on this form.
Please indicate your level of agreement with the following
information on your NEW prescription label compared to
your OLD prescription label:

Agree

Neither
Agree Nor
Disagree

Disagree

Strongly
Disagree

Don’t
Know

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

m

Strongly
Agree

I can easily find and read my name on the new label.
The name of the drug/medicine is clearly displayed on
the new label.
Reading the new label, I understand how to take the
medication correctly.
I can easily see how many refills are remaining on the
new label.
Overall, the new label is better than the old label.

Please use the back of this form to provide comments, and return the form to your VA Pharmacy.
VA Form 10-0549
MAY 2012

OMB 2900-0770
Estimated Burden: 4 min.

BACK OF CARD

Feedback Form
New VA Prescription Label

Please provide any comments you wish to share about the new VA presecription label.

Dear Veteran,
Thank you for providing feedback on the new VA prescription label. We value your opinion. Please do not identify
yourself on this form.
Please indicate your level of agreement with the following
information on your NEW prescription label compared to
your OLD prescription label:

I can easily find and read my name on the new label.

Strongly
Agree

m

Agree

Neither
Agree Nor
Disagree

Disagree

Strongly
Disagree

Don’t
Know

m

m

m

m

m

The name of the drug/medicine is clearly displayed on
m
m
m
m
m
m
the new label.
Reading the new label, I understand how to take the
m
m
m
m
m
m
medication correctly.
PRA Statement: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly,
I we
canmay
easily
howormany
refills
on the
not see
conduct
sponsor,
andare
youremaining
are not required
to respond to a collection of information unless it displays a valid OMB number.
m 4 minutes.
m This includes
m the time
m it
We anticipate
this consentm
form will average
new
label. that the time expended by all individuals who complete m
will take to read information provided and gather the necessary facts to fill out the form. Submission of this form is voluntary and failure
Overall,
thewill
new
label
is better
than the
label.
m
m
m
m
m
m
to respond
have
no impact
on benefits
to old
which
you may be entitled.

Please use the back of this form to provide comments, and return the form to your VA Pharmacy.
VA Form 10-0549
MAY 2012

OMB 2900-0770
Estimated Burden: 4 min.