Form VA Form 10-211010 VA Form 10-211010 Survey of Rehabilitation Care Survey

OMB 2900-0770
Estimated Burden: 5 min.

Expiration Date: XX/XX/XXXX

Department of Veterans Affairs

SURVEY OF REHABILITATION HEALTHCARE SERVICES

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 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.

Date:_____________________________ Clinic:_____________________________________

Your input is critical for us to continually improve, and to provide the best possible services to you. Information you provide is strictly private. Any comments made will not adversely affect your VA care.

Please circle the comment that best describes your experience today:

1. The person who checked me in for my appointment today was friendly and courteous.

Strongly Agree Agree Uncertain Disagree Strongly Disagree

2. How long after your scheduled appointment time did you wait to be seen?

No wait 1-10 minutes 11-20 minutes 21-30 minutes

Walk – in Clinic 31-60 minutes more than 1 hour

3. The healthcare provider(s) I saw for my appointment today was friendly and courteous.

Strongly Agree Agree Uncertain Disagree Strongly Disagree

4. The healthcare provider(s) I saw for my appointment today explained my medical condition
and/or the reason for my appointment.

Strongly Agree Agree Uncertain Disagree Strongly Disagree

5. I understand the plan for my care and the healthcare provider(s) I saw today included me in
the plan.

Strongly Agree Agree Uncertain Disagree Strongly Disagree

6. I got all the information I needed at my appointment today.

Strongly Agree Agree Uncertain Disagree Strongly Disagree

7. Any additional comments you would like to share? ________________________________________________________________________________________________________________________________________________________________________

Name of the healthcare provider(s) you saw today:________________________________________

Thank you for helping us serve you better!

VA Form 10-211010NR
OCT 2013

10-10059

VA Form
APR 2013

10-10058

VA Form
MAR 2013

Please return this form to the survey box.