10-10155 MEC Notification Survey

OMB No. 2900-0770

Estimated Burden: 4 Mins.

Expiration Date: XX/XX/XXXX

VA Delivery of the Affordable Care Act Minimum Essential Coverage Notification

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 4 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 currently be receiving.

VA Form 10-10155

VA Delivery of the Affordable Care Act Minimum Essential Coverage Notification Survey

1. On a scale of 1 to 5 with 5 being best, was the information presented understandable?

1. Did not understand

2. Slightly understood

3. Basic understanding

4. Moderate understanding

5. Best or complete understanding

2. On a scale of 1 to 5 with 5 being best, was the information correct?

1. Not correct

2. Somewhat correct

3. Basically correct

4. Moderately correct

5. Correct

• If not correct, please enter the correct information (comments section)

3. On a scale of 1 to 5 with 5 being completely, do you understand the reason for this notification?

1. Not completely understood

2. Somewhat of an understanding

3. Basic understanding

4. Moderate understanding

5. Complete understanding

4. Do you have any comments that will help us improve this mailing?