10-10125 Prosthetics Customer Service Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

Prothetics Customer survey FY14 (CR 8 21 14 v1)-3

Mental Health Survey, Prosthetics Customer Service Survey, Prosthetics Internal Survey, HME Survey

OMB: 2900-0770

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2900-0770 can be found here:

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OMB No. 2900-0770

Estimated Burden: 5 Minutes

OMB Expiration Date: XX/XX/XXXX

VISN 12 Prosthetics Internal Satisfaction Survey

VA Form 10-10125

The Paperwork Reduction Act of 1995: 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 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve improved mental health services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be receiving.

P ROSTHETICS & SENSORY AIDS SERVICE
INTERNAL CUSTOMER SATISFACTION SURVEY

Please take the time to complete this short survey on your experience with the Prosthetics employees today. We value your comments and feedback as they will help us improve our service. Thank you.

Date __________________________________ Facility ______________________________________

Valued Veteran or Family Member (optional) ________________________________________________

Name of Prosthetic employee assisting you today ___________________________________________

The person assisting me today was courteous and friendly