VA Form 10-211005 Patient Survey: Waiting Room Television Video Patient Ed

OMB 2900-0770
Estimated Burden: 5 min.

Patient Survey: Waiting Room Television Video Education
THE PAPERWORK REDUCTION ACT OF 1995 requires us to notify you that this information collected is in accordance
with the clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is
estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. No
person will be penalized for failing to furnish this information if it does not display a currently valid OMB control number.
Your obligation to respond to this survey is voluntary and failure to furnish this information will have no effect on any
benefits you are entitled.

1. Did you watch the education on the waiting room television?
YES

NO

2. How would you rate the education video?
Fair

Good

Very good

3. How was the video as an informative learning tool?
Fair

Good

Very good

4. How well did the education help you talk with your problem?
Fair

VA Form
June 2013

10-211005

Good

Very good