VA Form 10-0542 Spinal Cord Home Care Survey

OMB 2900-0770
Estimated Burden: 10 min.

Expiration Date: XX/XX/XXXX

SPINAL CORD INJURY

HOME CARE

PATIENT SATISFACTION SURVEY

OMB 2900-0770

VA FORM 10-0542

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 10 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.

SPINAL CORD INJURY – HOME CARE PATIENTS SATISFACTION SURVEY

The Spinal Cord Injury – Home Care Program is designed to assist you with your problems, needs,
and Goals. This survey is to assist SCI Home Care services in doing our job by helping you attain
maximum independence. Please answer the following. Circle the number for each statement that best matches your Opinion, using the following

I Strongly Disagree I Disagree I Agree I Strongly Agree

1 2 3 4

1. The Home Care staff returned my telephone calls in a timely manner, 1 2 3 4 with clinic appointments and consults.

2. The Home Care Staff sent appointment letters, giving enough notice. 1 2 3 4

2. The Home Care staff visited frequently enough to assist with my home 1 2 3 4

concerns and community adjustment.

4. The purpose of the SCI – Home Care Program was explained. I received a 1 2 3 4

SCI Home Care Handbook.

5. The Home Care staff discussed my medical problems and treatment with me. 1 2 3 4

The Home Care Staff explained the following:

6. How to order refills for medications (their name, use and side effect) and 1 2 3 4

supplies.

7. Who to contact if VA equipment breaks down (wheelchairs, beds, lifts, etc.) 1 2 3 4

7. How to dispose of medical waste such as needles and dressings. 1 2 3 4

7. Instruction on caregiver issues. 1 2 3 4

7. Instruction on benefits of financial concerns. 1 2 3 4

11. Do you have a better understanding of your SCI and how to take care of’ 1 2 3 4

yourself as a result of the home care services?

12. Did you take part in planning your discharge from home care services? 1 2 3 4

13. Were the services provided by the RN & Social Worker courteous and 1 2 3 4

helpful during home visits?

Overall, how would you rate the services provided by SCI Home Care?

Excellent Very Good Good Fair Poor

Comments ____________________________________________________

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VA Form 10-0542
October 2011

OMB 2900-XXXX
Estimated Burden: 5 min.

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