Form VA Form 10-0551 VA Form 10-0551 VCS Patriot Store and VCS Patriot Cafe Customer Satisfac

DEPARTMENT OF VETERANS AFFAIRS

P

OMB 2900-0770
Estimated Burden: 3 minutes

atriotStore

The VCS (Veterans Canteen Service) PatriotStore would like to get to know you,
our valued customer. Tell us what you think!

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 form will average 3 minutes. This includes the time it will take to read information provided and gather the necessary facts to fill out the form. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Gender? VA Employee?

Male Female Yes No

Veteran?

Yes No WW2 Korea Vietnam

OEF / OIF Other _______________

Age Group? under 25 26-40 41-55 56-70 71 or over

I am satisfied with the variety of products offered (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

The store atmosphere is clean and has a bright appearance (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

I am able to checkout in a timely manner (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

The PatriotStore offers value for the price (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

The staff is friendly, helpful and knowledgeable (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

How often do you normally shop in the PatriotStore?

daily 2-4 times a week once a week 2-4 times a month  once a month
 less than once a month  I rarely shop in the retail Patriot Store

Final comments and ideas are welcome…

T

VA Form 10-0551
June 2012

hank You - We Value Your Opinion

PatriotCafe

The VCS (Veterans Canteen Service) PatriotCafe would like to get to know you,
our valued customer. Tell us what you think!

Gender? VA Employee?

Male Female Yes No

Veteran?

Yes No WW2 Korea Vietnam

OEF / OIF Other ____________

Age Group? under 25 26-40 41-55 56-70 71 or over

I am satisfied with the menu variety offered (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

The cafe atmosphere is clean and has a bright appearance (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

I am able to checkout in a timely manner (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

The PatriotStore offers value for the price (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

The staff is friendly, helpful and knowledgeable (check one):

Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A

How often do you normally shop in the PatriotStore?

daily 2-4 times a week once a week 2-4 times a month  once a month 
 less than once a month  I rarely shop in the retail Patriot Store

Final comments and ideas are welcome…

T

VA Form 10-0551
June 2012

hank You - We Value Your Opinion