Mental Health - SORCC Satisfaction Survey

VA SORCC MHSL Satisfaction Survey

OMB No. 2900-0770
Estimated Burden: 2 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 2 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.

(<MH SERVICE/PROGRAM>) Customer Service Evaluation Date: ___________

Please tell us your level of satisfaction with the therapy services you received:

Overall how satisfied are you with the service you received

Very Dissatisfied_____  Mostly Dissatisfied _____  Neutral _____  Mostly satisfied _____ Very satisfied _____

Overall how satisfied are you with the service staff

Very Dissatisfied_____  Mostly Dissatisfied _____  Neutral _____  Mostly satisfied _____ Very satisfied _____

How likely are you to recommend this therapy to another Veteran?

Would you say the chances are …

Very Poor_____  Poor _____  Fair _____  Good _____ Excellent _____

Please tell us how you feel about the following statements:

“I got the service I needed”

Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree _____ Agree _____ Strongly Agree _____

“It was easy to get the service that I needed”

Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree _____ Agree _____ Strongly Agree _____

“I felt like a valued customer”

Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree _____ Agree _____ Strongly Agree _____

“I trust the VA to fulfill our country’s commitment to Veterans”

Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree _____ Agree _____ Strongly Agree _____

Comments (Please include anything you think would be helpful for improving this therapy or any general comments):

2