Form VA Form 10-10164 VA Form 10-10164 VISN 20 Cancer Care Survey

OMB Number 2900-0770

Estimated Burden: 5 min

Expiration Date: XX/XX/XXXX

VISN 20 Cancer Care Survey

OMB Number 2900-0770

Estimated Burden: 5 min

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 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

Thank you for taking the time to respond to these questions. Your input is important to improve care.

Age: _______

Gender:  Male  Female

Where is your home VA for Primary Care?

 Anchorage, AK  Boise, ID  Portland, OR  Puget Sound, WA

 Roseburg, OR  Spokane, WA  Walla Walla, WA  White City, OR

Cancer Type:

 Bladder

 Breast

 Colon/Rectum

 Esophageal

 Head & Neck

 Leukemia/Lymphoma

 Liver

 Lung

 Melanoma

 Myeloma

 Pancreatic

 Prostate

 Women’s

 Other:

_________________________

Where have you received cancer treatment? (check all that apply)

 Boise VA Medical Center	 VA Puget Sound Health Care System	 Other VA Facility
 VA Portland Health Care System	 Spokane VA Medical Center	 Non-VA Facility (community)

Did a member of the VA Cancer Care Navigation Team (CCNT) work with you during your cancer care?

 Yes, I worked with: _____________________________  No  Unsure

Please indicate how much you agree with each statement below for your VA cancer care experience:

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree	N/A
I received care in a timely manner	5	4	3	2	1
I knew what to expect through each stage of my care	5	4	3	2	1
My transitions between VA facilities for care were smooth	5	4	3	2	1
My transitions between VA and the community for care were smooth	5	4	3	2	1
The staff provided support for my family/caregiver	5	4	3	2	1
I received adequate information/education on my diagnosis	5	4	3	2	1
I knew who to call if I had questions or concerns	5	4	3	2	1
I am satisfied with the Cancer Care Navigation Team (CCNT)	5	4	3	2	1
Overall, I am satisfied with VA cancer care	5	4	3	2	1

How can we improve the VA cancer care experience?

Do you have any other comments you would like to make? (continue comments on back as needed)