Form VA Form 10164 VA Form 10164 CFM Supplier Electronic Comment Card

OMB 2900-0770
Estimated Burden: 2 minutes
Expiration Date: XX-XX-XXXX

Department of Veterans Affairs
Office of Construction and Facilities Management (CFM) Supplier Comment Card
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this
collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, and
completing and reviewing the collection of information. No person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number. Customer satisfaction surveys are
used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this
survey will lead to improvements in the quality of service delivery by helping to shape the direction and focus of specific,
programs and services. Submission of this form is voluntary and failure to respond will have no impact on benefits to
which you may be entitled.

Thank you for accessing the VA Office of Construction and Facilities Management (CFM) Supplier Comment Card. You
may use this comment card to provide feedback on support you have received from CFM. Click "Done" at the bottom of
this page to complete the survey and submit your responses.

1. Please select the option below that best describes you.
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Other (please specify)

2. What type of feedback do you want to provide on your recent interaction with CFM?
 Pre-Solicitation Support: RFI submission, RFI questions
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 Contract Award Support: Contract Award, Kick-Off Meetings
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 Solicitation Support: RFP submission, RFP questions
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 Post-Award Support: Invoicing, Payments, Project Management,
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Change Orders

Other (please specify)

3. Please rate your satisfaction with the following aspects of the support you received
from CFM on a scale of 1 (Extremely Dissatisfied) to 10 (Extremely Satisfied).
1
(Extremely

10
2

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9

Dissatisfied)

(Extremely
Satisfied)

Can't
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Responsiveness of Staff

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Professionalism of Staff

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Accessibility of Staff

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Quality of Communications

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Timeliness of

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Quality of Service Provided

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Timeliness of Service

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Communications

Provided
Overall Satisfaction

VA Form 10164

4. Please use the space below to provide any additional feedback you would like. NOTE: If
you wish for your survey responses to remain anonymous, do not provide personal
identifying information; as your comments will be viewable by VA and CFM personnel.




5. If you wish to receive follow up from CFM on your survey responses, please provide
your contact information below. NOTE: Please do not provide contact information if you
wish for your survey responses to remain anonymous.
Your Name:
Your Company Name:
Your Company Email
Address:
Your Company Phone
Number:

VA Form 10164