Form VA Form 10-0480 VA Form 10-0480 Compensation and Pension Examination Program (CPEP) Vete

OMB 2900-XXXX
Estimated Burden 5.7 min.

Compensation and Pension Examination Program (CPEP)
Veteran Satisfaction 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 5.7
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 current valid OMB control number. This collection of information is intended to fulfill the need identified by the
Department of Veterans Affairs in their call for evaluation and improvements to the current Patient Satisfaction program. Your obligation to
respond to this survey is voluntary and failure to furnish this information will have no effect on any of your benefits.

Q1

Using any number from 1 to 5 where 5 is the
best clinician possible, what number would you
use to rate the C&P clinician you saw on your
last visit?
1

2

3

4

Q5

5

Poor

Cleanliness of
the room

Please select one.

Q2

2

3

4

Fair

Good

Very
ExcellGood Excellent
ent

Cleanliness of the
reception/waiting
area

Using any number from 1 to 5 where 5 is the
best clerk/receptionist possible, what number
would you use to rate the C&P clerk
receptionist you saw on your last visit?
1

Ease of finding the
C&P department
within the facility
How would you rate
the clinic building
overall (i.e.
attractiveness of
facility appearance,
quality of building
maintenance and
upkeep)?

5

Please select one.

Q3

How would you rate the following aspects of
the examination or treatment room, equipment
and facilities?

On the day of your appointment, how long did
you wait in line to check in?

In terms of your
satisfaction, how
would you rate the
convenience of the
location of the clinic
facility?

No Wait ..................................................................
1 to 10 minutes ......................................................
11 to 20 minutes ....................................................
21 to 30 minutes ....................................................
31 to 60 minutes ....................................................

Q6

more than one hour ...............................................

All things considered, how satisfied were you
with the VA during your recent C&P visit?
Completely satisfied ..............................................

Q4

How long after the time when your appointment
was scheduled to begin did you wait to be seen?

Very satisfied ........................................................
Neither satisfied nor dissatisfied ............................

No Wait ..................................................................

Very dissatisfied ....................................................

1 to 10 minutes ......................................................

Completely dissatisfied .........................................

11 to 20 minutes ....................................................
21 to 30 minutes ....................................................
31 to 60 minutes ....................................................
more than one hour ...............................................

VA From 10-0480
December 2009

Q7

Please provide any comments that will help
improve the C&P experience for veterans.