Health Advocate Survey

Health Advocate Proof of Concept Pilot Project Patient Satisfaction Assessment

OMB No. 2900-0770
Estimated Burden: 5 Minutes

Expiration Date: 08/31/2017

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

Please circle answer that best describes your experience at today’s appointment.
1. Compared to your prior visits to this clinic, how would you rate today’s appointment? If this is your first visit please skip to Question 3.
Much better	Somewhat better	Same	Somewhat worse	Much worse
2. Compared to past visits, my provider focused on the computer ___________________________
Much less	Somewhat less	Same	Somewhat more	Much more
3. How comfortable were you with speaking openly to your provider about your health concerns with other staff present during your visit?
Very comfortable	Somewhat comfortable	Neutral	Somewhat uncomfortable	Very uncomfortable
4. How helpful was the health education you received during your visit?
Very helpful	Somewhat helpful	Neutral	Somewhat unhelpful	Very unhelpful
5. How comfortable were you with staff writing notes in the computer throughout your visit with the provider?
Very comfortable	Somewhat comfortable	Neutral	Somewhat uncomfortable	Very uncomfortable