VA Form 10-0554 Office of Mental Health Veteran Satisfaction Survey

DEPARTMENT OF VETERANS AFFAIRS

OMB 2900-XXXX
Estimated Burden 15 minutes

Expiration Date: XX/XX/XXXX

Office of Mental Health Veteran Satisfaction Survey
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 this Act. 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 15 minutes. This includes the time it will take to read information provided and gather the necessary facts to fill out the form. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled. Responses to the survey will be reported in aggregate form and will be anonymous.
For each item identified below, circle the number to the right that best fits your judgment of its occurrence at your facility. Use the scale above to select the frequency number.
Survey Item		Strongly Disagree		Disagree		Neither Disagree or Agree		Agree		Strongly Agree		NA or Unknown
I get appointments with my mental health provider on the day that I want or within two weeks of the day that I want		1			2		3		4		5	NA
I can see my mental health provider who prescribes my medications as frequently as needed		1			2		3		4		5	NA
If I have a question about my psychiatric medications, I can get in touch with a mental health provider or pharmacist by phone to get my question answered		1			2		3		4		5	NA
I talk to the person who prescribes my mental health medication by Telemental health (V-Tel)		1			2		3		4		5	NA
I talk to my counselor/therapist by Telemental health (V-Tel)		1			2		3		4		5	NA
There are problems getting the Telemental health (V-Tel) equipment to work		1			2		3		4		5	NA
Mental health treatment has been helpful in my life		1			2		3		4		5	NA
I was able to choose which of the psychotherapies I wanted to try after good discussion with my mental health provider about the options		1			2		3		4		5	NA
I believe it is necessary for me to stay in mental health treatment to keep my service connected disability		1			2		3		4		5	NA
I would like to schedule mental health appointments during extended hours (early mornings, evenings, or on weekends)		1			2		3		4		5	NA
It is hard to get to my mental health appointments because of transportation problems		1			2		3		4		5	NA
Parking is a problem at my facility		1			2		3		4		5	NA
My mental health appointments are scheduled by VA without any input from me		1			2		3		4		5	NA
I get a reminder call or letter about my mental health appointments		1			2		3		4		5	NA
I attend group mental health treatment, and the room comfortably fits all the group participants		1			2		3		4		5	NA
When I have an individual mental health session with my provider, we meet in a room that is private		1			2		3		4		5	NA
I know that I will get a call back if I leave a message for my mental health provider		1			2		3		4		5	NA
My mental health provider and I agree on how often I should have appointments		1			2		3		4		5	NA
I can’t see my mental health provider as much as I should because the provider does not have time to see me		1			2		3		4		5	NA
I VA Form 10-0554 JULY 2012 am comfortable in the waiting area for mental healthcare		1			2		3		4		5	NA
Survey Item	Strongly Disagree		Disagree				Neither Disagree or Agree	Agree		Strongly Agree		NA or Unknown
The staff is open to my suggestions regarding improvements to mental health services		1			2		3		4		5	NA
I am treated with respect and kindness at the mental health programs		1			2		3		4	5		NA
During our appointments, my mental health provider focuses on the computer rather than engaging with me in face-to-face eye contact		1			2		3		4	5		NA
I know that there are mental health providers available right in Primary Care		1			2		3		4	5		NA
My primary care provider prescribes my psychiatric medications, such as medicine to help with depression or nervousness		1			2		3		4	5		NA
My family has been involved in mental health treatment with me as much as I would like them to be involved		1			2		3		4	5		NA

WRITE IN SECTION:

27. My Mental Health Treatment Coordinator is:___________________________________________________________

28. The biggest problem or concern I have about Mental Health Treatment is: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

29. The biggest compliment or positive I have about Mental Health Treatment is:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If you wish to discuss your experience, please feel free to contact your Mental Health Treatment Coordinator, facility Mental Health Chief, Local Recovery Coordinator, or other Mental Health staff.

VA Form 10-0554 JULY 2012