Veterans Transportation Survey

Veteran's Transportation Services
(VTS)

Customer Satisfaction Questionnaire

OMB 2900-0770

VA Form 10-0517

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 will average 5.7 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. 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 improvement in the quality of service delivery by helping to shape the direction and focus of specific programs or services. Completion of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

	Veteran's Transportation Services (VTS) Customer Satisfaction
	This questionnaire is anonymous and will only be used to improve your experience with our transportation service. You are not obligated to complete the questionnaire and may answer as many of the questions as you want or none at all.

1.	Are you eligible for VA travel pay?
		Yes
		No
		Don't know

2.	Have you missed appointments due to lack of transportation in the past?
		Yes
		No

3.	How do you get to your medical appointments when you are not using this transportation service?
		I drive myself
		Public transportation
		No other transportation
		Family member/friend drives me
	Other
	___________________________________________________________________________________________________________________________________________________________________________________________________

4.	Overall, how would you evaluate the following?
		Excellent		Good		Fair		Poor
	Vehicles are clean							
	Drivers are friendly and helpful							
	Vehicles are on time							
	Schedules are easy to find							
	Frequency of service is convenient							
	The right destinations are served							
	Overall Service							

5.	Would you use our service (VTS) again in the future?
		Yes
		No

6.	Would you recommend our services to another Veteran?
		Yes
		No

7.	Which medical center do you use for care?
	___________________________________________________________________________________________________________________________________________________________________________________________________

8.	Please provide any comments that will help us provide the best transportation service to Veterans.
	___________________________________________________________________________________________________________________________________________________________________________________________________