Form VA Form 10-211014 VA Form 10-211014 Home Based Primary Care Survey

OMB 2900-0770
Estimated Burden: 8 min.

Department of Veterans

Lawton CBOC Home Based Primary Care (HBPC) Program
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 8
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.

Please indicate your response to the following questions regarding your HBPC Services.
1=Strongly Disagree 2=Disagree 3=Not Certain 4=Agree 5=Strongly Agree
N/A=Not Applicable
HBPC was explained to me

1

2

3

4

5

N/A

The information I received was easy to understand

1

2

3

4

5

N/A

HBPC visits were made as scheduled or canceled
with notice

1

2

3

4

5

N/A

I have trust and confidence in the HBPC team

1

2

3

4

5

N/A

When I questioned my care, I got answers I
understood

1

2

3

4

5

N/A

My pain was addressed during the Primary Care
Provider (PCP) visit

1

2

3

4

5

N/A

The nurse explained my medication usage to me

1

2

3

4

5

N/A

Department
ofcould
Veterans
Affairs
HBPC staff did everything
they
to control
my
pain

1

2

I am able to suggest ways to improve my safety

1

2

3

4

5

N/A

I am satisfied with the overall quality of services/care
provided by the HBPC team

1

2

3

4

5

N/A

My telephone calls to HBPC were returned in a
timely manner

1

2

3

4

5

N/A

Someone discussed Advanced Directives with me
(ie Living Will, Durable Power of Attorney [DPOA])

1

2

3

4

5

N/A

When calling HBPC staff were courteous and
respectful

1

2

3

4

5

N/A

I was instructed on how to use my home equipment
safely (ie wheelchair, walker, cane, nebulizer,
hospital bed, or Hoyer Lift)

1

2

3

4

5

N/A

I feel I am an active participant in my healthcare

1

2

3

4

5

N/A

I understand the goals for my care

1

2

3

4

5

N/A

Someone discussed fall safety with me

1

2

3

4

5

N/A

VA Form
DEC 2013

10-211014

Patient Satisfaction Survey
3
4
5
N/A