VA Form 10-211004 Project ARCH Non-Participant Survey

OMB 2900-0770
Estimated Burden: 15 min.

PROJECT ARCH (Access Received Closer to Home)

Non-Participating Veterans Survey
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
15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and r eviewing the collection of information. No person will be pena lized 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.

Project ARCH (Access Received Closer to Home) is a pilot program operated by the Department of Veterans Affairs
(VA) that allows eligible Veterans to receive care from non-VA medical providers near their homes. According to our
records, you are eligible to participate in Project ARCH, but have not received care through the program.
Your answers to the following short questionnaire will help VA understand the reasons why some Veterans have not
participated in Project ARCH.
Your answers and feedback are important to help VA improve the pilot program. Participation in this survey is entirely
voluntary and all information is strictly private to the extent of the law. Participation in this survey will not affect your VA
medical care.
Please read each question and check the box that best describes your opinion, using blue or black ink pen. Please be
sure to read all the pages of this questionnaire.
When answering the questions, think only about the reasons why you haGFDUHRQ>'DWH@IURP>'RFWRU+RVSLWDO@ UDWKHU
than receiving the medical care through Project ARCH.
Thank you very much!
INSTRUCTIONS
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Answer all questions below according to the instructions given. For question number 1 and questions 6-9, please
check the box to the left of your answer. For questions 2 through 4, please check the box to the right that
corresponds to your answer. For question numbers 5 and 10, please fill in your answer in the blanks provided.
Please use black or blue ink pen.
You are sometimes asked to provide further explanation in this survey. When this happens, you will see a blank
line under the option "Other," like this:
Other (Please explain below)
_______________________________________
Please explain further by writing on top of the blank line legibly.

INTRODUCTION
1. How did you first find out about Project ARCH? (select all that apply)
 VA provider (from the doctor, nurse practitioner, PA, or other medical professional)
 Project ARCH nurse care coordinator
 Other VA staff
 Project ARCH website
 Project ARCH provider
 Veteran Service Organization
 Other Veterans
 I have not previously heard about Project ARCH (Go To Question 6)

VA Form 10-211004
June 2013

2. What Project ARCH information did you receive and was it useful?
Yes

No

N/A

a. Letter, brochure or pamphlet
If yes, was it useful?
b. Consent form
If yes, was it useful?
c. Project ARCH staff contact information
If yes, was it useful?
d. Project ARCH website address
If yes, was it useful?
e. Verbal explanation from a VA staff member.
If yes, was it useful?

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f.

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Frequently Asked Questions (FAQ)
If yes, was it useful?
g. Other (please explain below)
________________________
If yes, was it useful?

REASONS FOR CHOOSING NOT TO ENROLL IN PROJECT ARCH

A. I have an established, long term relationship with VA that I do not want to
give up.
B. I have an established relationship with my VA medical provider that I do
not want to give up.
C. The coordination of my medical care, labs, and records would be more
difficult if I enrolled in Project ARCH.
D. I am satisfied with the care I get from VA doctors and hospitals and do
not want to switch doctors or hospitals.
E. I have other appointments that require me to travel to a VA Medical
Center or clinic; Project ARCH would not save me travel time.
F. I heard negative comments about Project ARCH from other Veterans.
G. I heard negative comments about Project ARCH from VA staff.
H. I moved out of the eligibility area for Project ARCH.
I.

The doctors or hospitals offered to me were not conveniently located.

J.

I did not want to receive medical care from the doctors or hospitals
offered to me.

K. I can receive care sooner through VA than through Project ARCH.

VA Form 10-211004
June 2013

Completely
Agree

Somewhat
Agree

Neither Agree or
Disagree

Somewhat
Disagree

Reason for Not Enrolling in Project ARCH

Completely
Disagree

3. The table below lists statements that may be possible reasons for not receiving care through Project ARCH. Please tell
us a little bit about how much these factors apply to you by checking the box that represents how much you agree with
each statement.

Completely
Agree

Somewhat
Agree

Neither Agree or
Disagree

Somewhat
Disagree

Reason for Not Enrolling in Project ARCH

Completely
Disagree

4. Here are a few more possible reasons for not receiving care through Project ARCH. Please check the box that
represents how much you agree with each statement.

A. I rely on the travel pay that I get for traveling to VA facilities for care.
B. I have free transportation to the medical center or outpatient clinic; getting
care close to home is not very important.
C. I did not want to enroll in a short-term pilot program that will end after 3
years.
D. It seemed like too much trouble to figure out the program.
E. I was afraid I would lose all access to VA medical care if I enrolled in
Project ARCH.
F. I wanted to participate in Project ARCH, but never received follow-up
information.
G. Project ARCH physicians and hospitals do not understand how to provide
care for Veterans.
H. I use my Medicare or private insurance for most of the medical care I
need.
I.

I was concerned that VA might bill me for care provided under Project
ARCH that should be covered by VA.

J.

VA pays for the care I need at a non-VA facility or doctor near my home
through “fee-basis” or another VA program

K. I did not need any of the services offered through Project ARCH
5. Are there any other reasons we have not asked about that discouraged you from receiving care through Project ARCH?
On the lines below, please describe your other reasons for not receiving care through Project ARCH (please print legibly).

VA Form 10-211004
June 2013

ABOUT YOURSELF
6. In general, how would you rate your overall health?
 Excellent
 Very Good
 Good
 Fair
 Poor
7. In general, how would you rate your overall mental health?
 Excellent
 Very Good
 Good
 Fair
 Poor
8. Please select all that apply. Other than VA are you currently enrolled in:
a) TRICARE
 YES
 NO
b) Medicare
 YES
 NO
c) Medicaid
 YES
 NO
d) Civilian/Employer-Sponsored
Health Insurance
 YES
 NO
e) Private/Purchased Health Insurance
f) VA only

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

YES
YES

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

NO
NO

9. Please select one that applies to you.
 I use VA for all my care
 I use VA for most of my care
 I use VA for some of my care

10. Is there anything else you would like to tell us that is related to Project ARCH?

THANK YOU
Your answers are important to help us improve access to care for Veterans like yourself. Thank you for completing this
questionnaire. Please place the completed questionnaire in the postage-paid envelope provided to you. Simply place the
envelope in any mailbox and the survey will be returned to:
Department of Veterans Affairs
C/o DataStat
3975 Research Park Drive
Ann Arbor, MI 48108

VA Form 10-211004
June 2013