PTSD Consultation Program

National Center for PTSD (Posttraumatic Stress Disorder)

PTSD Consultation Program Feedback Survey

OMB No. 2900-0770
Estimated Burden: 10 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 10 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 excellent consultation services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Feedback Survey
Please take a few minutes to answer these questions about your consultation request on [date] and the response you received from consultant(s) [Name(s)].  Your feedback is important to us and will help us to sustain and improve this program.  This should take approximately 10 minutes to complete.
When you are finished please click the SUBMIT button below.  If you have any questions or problems with the form please email PTSDconsult@va.gov.  Thank you for your help.
	Very Dissatisfied	Dissatisfied		Neither Satisfied nor Dissatisfied		Satisfied			Very Satisfied
Overall, how satisfied were you with your consultation experience?
Please rate these specific aspects of your consultation experience using this scale:	Poor		Fair		Good		Very Good	Excellent
My initial contact was responded to in a timely manner
Consultation length was appropriate for my question
Options and/or next steps were offered
Met my goals for contacting the PTSD Consultation Program
Comments about any of your responses?	[text box for comments]
Please rate the consultant of your consultation experience using this scale:	Poor		Fair		Good		Very Good	Excellent
Interacted with me in a collaborative way
Delivered knowledgeable and thoughtful recommendations that were useful
Comments about either of your responses?	[text box for comments]
	Probably Not		With Reservations		Probably		Most Definitely
Would you recommend the Consultation Program to a colleague or other clinicians?
Is there anything else you would recommend for the PTSD Consultation Program?	[text box for comments]