10-0455 Nationwide Dialysis Program Survey

OMB Number 2900-0770

Estimated Burden: 5 mins

EXP Date: XX/XX/2017

Nationwide Dialysis Contracts Program Veterans Survey

OMB 2900-0770

Estimated burden: 5 minutes

Expiration Date xx/xx/xxxx

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 five (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 services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Thank you for your willingness to help us improve our dialysis services.

The survey uses the following phrases as defined:

• “VA” refers to the Department of Veterans Affairs and care provided in a VA facility.

• “Non-VA Provider” refers to a non-VA community dialysis provider and care provided in the home or at a non-VA facility.

#	Question
1	Please enter the Unique Identification Code that was provided on your survey invitation letter. (This number is 7-9 characters long) (Text box)
2	What is your level of satisfaction with how clearly VA staff explained the transfer of your dialysis treatments from VA to a non-VA provider? Highly Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Highly Dissatisfied
3	How satisfied are you with the transition experience from VA to your non-VA provider? Highly Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Highly Dissatisfied
4	After your initial appointment scheduled by VA, how satisfied are you with the scheduling process followed by your non-VA provider? Highly Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Highly Dissatisfied
5	Where do you receive your dialysis treatments? Home Non-VA provider facility Q11
6	How satisfied are you with the training that was provided to receive your dialysis treatments at home? Highly Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Highly Dissatisfied
7	Did your in-home provider give you the tools, knowledge and equipment to effectively manage your dialysis treatments? Yes No
8	Did your in-home provider answer any questions you may have had in a satisfactory manner? Yes No
9	Did your in-home provider give you appropriate points of contact in case you had follow-up questions or concerns? Yes No
10	Is there anything you would like to share regarding your in-home dialysis treatments? No Q17 Yes Q17 (Text Box)
11	How far do you have to travel from home to your non-VA provider facility? less than 10 miles 10 to 20 miles 21 to 30 miles more than 30 miles
12	How satisfied are you with the convenience of your non-VA provider facility location? Highly Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Highly Dissatisfied
13	How satisfied are you with the quality of care provided by the clinical staff at your non-VA provider facility? Highly Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Highly Dissatisfied
14	On average, how long do you have to wait for your dialysis treatments after your appointment time at the non-VA provider facility? less than 15 minutes 15 to 30 minutes 31 minutes to 1 hour more than 1 hour
15	Do the clinical staff at the non-VA provider facility show concern for your well-being during your dialysis treatment? Yes No ( Text Box)
16	Is the physical environment at the non-VA provider facility comfortable during your dialysis treatment? Yes No ( Text Box)
17	Have you ever received a bill from your non-VA provider? Yes No
18	Did you receive a copy of the Patients’ Rights and Responsibilities from your non-VA provider? Yes No
19	Do you know how to inform VA should you have a concern regarding your non-VA provider? Yes No
20	Overall, how satisfied are you with your dialysis treatment experience? Highly Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Highly Dissatisfied
21	Is there anything that you would like to share about your dialysis care? No Yes (Text Box)