Form 10-10074 CSP Customer Satisfaction Survey

OMB Number: 2900-0772
Estimated Burden: 10 minutes

Expiration Date: XX/XX/XXXX

Cooperative Studies Program (CSP)
Customer Satisfaction Survey

Respondent Burden Statement: 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 read instructions, gather the necessary facts and fill out the form. Disclosure of information involves release of statistical data and other non-identifying data for the improvement of services within the VA healthcare system and associated administrative purposes. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

CSP Customer Satisfaction Survey

Check one: ------ I am a study site investigator

------ I am a study coordinator

I have worked on this study for 1 year or more _____ Yes _____ No

Rate your satisfaction with the services you received from the _________ (insert name of Center) in the last 12 months. If the study was recently initiated, consider the time period from study funding to present. This survey will be available for 30 days for your feedback and comments.

Part 1 Overall Satisfaction

The following questions are designed to gather feedback on the overall satisfaction with the quality of services received from the _________ (insert name of Center) using the 5 point scale below where:

1=strongly disagree

2=disagree

3=neither agree or disagree

4=agree

5=strongly agree

Check the box next to the answer that best describes your overall satisfaction with the _____(insert name of Center).

I am satisfied with the services provided.

1 2 3 4 5

strongly disagree neither agree agree strongly

disagree or disagree agree

I am satisfied with the quality of the services provided.

1 2 3 4 5

strongly disagree neither agree agree strongly

disagree or disagree agree

Part 2 Accessibility and Responsiveness

The following questions are designed to gather feedback on the staff’s accessibility and responsiveness to your needs received from the _________ (insert name of Center) using the 5 point scale below where:

1=strongly disagree

2=disagree

3=neither agree or disagree

4=agree

5=strongly agree

Check the box next to the answer that you best describes the accessibility and responsiveness of the _____(insert name of Center) staff.

I am satisfied with the accessibility of coordinating center staff when I need to reach them.

1 2 3 4 5

strongly disagree neither agree agree strongly

disagree or disagree agree

If you answered 1 or 2 please check the staff who were not accessible. You may check more than one box if needed.

______ Biostatistician

______ Project Manager

______ Other (specify by title) __________________

I am satisfied with the promptness of coordinating center staff when returning telephone calls.

1 2 3 4 5

strongly disagree neither agree agree strongly

disagree or disagree agree

I am satisfied with the promptness of coordinating center staff when responding to emails.

1 2 3 4 5

strongly disagree neither agree agree strongly

disagree or disagree agree

I get timely communications involving study issues.

1 2 3 4 5

strongly disagree neither agree agree strongly

disagree or disagree agree

Part 3 Courtesy, Knowledge, and Professionalism

The following questions are designed to gather feedback on the staff’s courtesy, knowledge, and ability from the _________ (insert name of Center) using the 5 point scale below where:

1=strongly disagree

2=disagree

3=neither agree or disagree

4=agree

5=strongly agree

Check the box next to the answer that you feel best describes the courtesy, knowledge, and ability of the _____(insert name of Center) staff.

I am satisfied with the courtesy of CSP Coordinating Center staff

1 2 3 4 5

strongly disagree neither agree agree strongly

disagree or disagree agree

I am satisfied with the knowledge of CSP Coordinating Center staff

1 2 3 4 5

strongly disagree neither agree agree strongly

disagree or disagree agree

I am satisfied with the professionalism of CSP Coordinating Center staff

1 2 3 4 5

strongly disagree neither agree agree strongly

disagree or disagree agree

Part 4 Process Specific Questions

The following questions are designed to gather feedback with the services, documents, and processes developed to support your study from the____(insert name of Center) using the 5 point scale below where:

1=strongly disagree

2=disagree

3=neither agree or disagree

4=agree

5=strongly agree

NA = does not apply

If a question does not apply to you or your site, for whatever reason, please choose NA (does not apply).

Check the box next to the answer that you feel best describes your satisfaction with specific services for the _____(insert name of Center).

I am satisfied with the support to answer questions regarding the Institutional Review Board submission(s)

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

I am satisfied with the content of the last major study meeting. (this would include an initial study kick off meeting(s) or annual meeting).

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

The study conference calls convey useful information

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

The study operations manual is complete

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

The study case report forms are clear

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

The electronic data capture (EDC) training and education is helpful

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

The technical support for use of the electronic data capture (EDC) system is appropriate

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

Data queries are clear

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

The assistance to support data collection/completion is appropriate

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

The assistance to complete study close out procedures is appropriate

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

The organization and usefulness of the study SharePoint site is appropriate

1 2 3 4 5 NA

strongly disagree neither agree agree strongly Does not apply

disagree or disagree agree

For responses indicating a 1 (strongly disagree) or 2 (disagree) please provide additional detail to assist us in developing meaningful improvements: ____________________________________________________________________________________________________________________________________________________________

Part 5 Willingness to Recommend

Answer the following question about your willingness to recommend working with the (insert name of Center) for future CSP studies using the following 5 point scale where:

1=definitely will not recommend

2=might not recommend

3=neither not recommend or recommend

4=might recommend

5=definitely will recommend

If asked by a colleague, how willing would you be to recommend the _____(insert name of Center). to work with you on your future CSP research?

1 2 3 4 5

definitely might neither might definitely

will not not recommend recommend will

recommend recommend or recommend recommend

Do you have any needs that we are currently not addressing?

___________________________________________________________________________________________________________________________________________________________

Do you have any comments, complaints, or concerns about the____(insert name of Center)?

____________________________________________________________________________________________________________________________________________________________

Do you have any compliments or recognitions involving particular people at the ____(insert name of Center)?

____________________________________________________________________________________________________________________________________________________________

You may include your name on this survey. (Optional) ______________________________________________________________________________

If you would like to speak to someone personally about this survey or the service you receive, please contact XXX at the XX CSP Coordinating Center by calling XXX XXX XXXX.

VA Form 10-10074
JAN 2014