Form 10-10130 VISN 4 Audience Feedback Questionnaire

OMB No. 2900-XXXX
Estimated Burden: 5 min.

Expiration Date: xx/xx/xxxx

From War To Home

Audience Feedback Questionnaire

VA Form 10-10130

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 05 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 help us understand the potential impact that attending this kind of event can have on different audiences. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

We invite you to share your feedback on the presentation by completing this anonymous questionnaire. Your comments will help us understand the potential impact that attending this kind of event can have on different audiences.

Please return your completed questionnaire to us by leaving it on your chair or placing it in the envelope provided. Thank you in advance for your participation!

1. In what capacity are you attending today’s presentation? (Check all that apply)

I am a Veteran

I am a family member of a Veteran

I am a friend of a Veteran

I am a VA employee

I am a clinician (please specify) _________________________

I am a researcher

I am an educator

I am a student

(Other – please specify): ___________________________________________

2. Please share your personal experience of today’s presentation by completing the following phrases:

1. I was surprised to learn ________________________________________________________________
   ____________________________________________________________________________________
   ____________________________________________________________________________________

2. For me, the most meaningful thing about the presentation was _______________________________ ____________________________________________________________________________________
   ____________________________________________________________________________________

3. This presentation changed the way I _____________________________________________________
   ____________________________________________________________________________________
   ____________________________________________________________________________________

4. After attending this presentation, I still wish I knew more about ______________________________
   ____________________________________________________________________________________
   ____________________________________________________________________________________

5. For me, the overall message of the presentation was ________________________________________
   ____________________________________________________________________________________
   ____________________________________________________________________________________

3. Please rate your agreement with the following statements:	1 Strongly Disagree	2 Disagree	3 Agree	4 Strongly Agree
I feel more confident in my ability to connect with veterans than I did before today’s presentation.	1	2	3	4
The presentation made me more aware of how diverse veterans’ experiences and stories are.	1	2	3	4
The presentation challenged me to rethink some of my own assumptions about veterans.	1	2	3	4
Attending this presentation helped me better understand the challenges veterans face coming home after a deployment.	1	2	3	4
3 e-f: Veterans only
This presentation reminded me of my own experiences.	1	2	3	4
Attending this presentation was a healing experience for me.	1	2	3	4
Attending this presentation made me feel less alone in my experiences.	1	2	3	4
Attending this presentation makes me feel like it will be easier for me to share my own story with others.	1	2	3	4

Please use the space below for any other comments you want to share about today’s presentation.