Form 10-0341 VHA Telehealth Services HT Patient Satisfaction Survey

OMB 2900-0766

Estimated Burden 2.5 minutes

Expiration Date: XX/XX/XXXX

Telehealth Services - Home Telehealth (HT)

Patient Satisfaction Survey

VA Form 10-0481

Home Telehealth Patient Satisfaction Survey

Dear Veteran Patient,

It is very important that we know what you think about the Home Telehealth program. Your responses to this electronic survey will help us learn how we can improve our care to all veterans. We would greatly appreciate you taking a few minutes to complete the electronic satisfaction survey either on your telehealth device or through the Interactive Voice Response technology, whichever has been assigned to you.

First, we’d like you to know:

• Your device or the Interactive Voice Response technology will send the satisfaction survey to you about 30 days following your enrollment into the HT program and then will occur about every 90 days after that.

• Your responses to the satisfaction survey questions are transmitted electronically to the vendor’s server (which is located behind the VA firewall) to a special dataset where VA Information Technology staff analyze and combine all responses into a report.

• Your responses are confidential and are not viewable by your care coordinator at any time.

• You may choose to not answer the satisfaction survey questions each time they are presented on your device or electronically through the Interactive Voice Response technology.

• Even if you choose not to participate in the satisfaction survey at any time, you must continue to respond to your daily health questions that are presented to you.

• Please remember that your responses are important information to help us improve care to all veterans

Thank you for your time.

Home Telehealth (HT) Patient Satisfaction Survey

THE PAPERWORK REDUCTION ACT OF 1995 requires us to notify you that this information collected is in accordance with the clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average 2.5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. No person will be penalized for failing to furnish this information if it does not display a current valid OMB control number. This collection of information is intended to fulfill the need identified by the Department of Veterans Affairs in their call for evaluation and improvements to the current Patient Satisfaction program. Your obligation to respond to this survey is voluntary and failure to furnish this information will have no effect on any of your benefits.

1. My care coordinator explains things in a way that is easy to understand.

• Always

• Usually

• Sometimes

• Never

2. The information provided by my care coordinator has helped me manage my health problem(s).

• Strongly Agree

• Agree

• Disagree

• Strongly Disagree

3. Over the past 3 months, my home telehealth equipment works:

• Always

• Usually

• Sometimes

• Never

4. My home telehealth equipment is easy to use.

• Strongly Agree

• Agree

• Disagree

• Strongly Disagree

VA Form 10-0481 December 2009

5. I have made changes in the way I take care of myself as a result of the VA home telehealth program.

• Strongly Agree

• Agree

• Disagree

• Strongly Disagree

6. When I have questions, I am able to contact my care coordinator during business hours.

• Always

• Usually

• Sometimes

• Never

7. Using the VA home telehealth program has made a positive difference in my health.

• Strongly Agree

• Agree

• Disagree

• Strongly Disagree

8. I would recommend a home telehealth program to others.

• Strongly Agree

• Agree

• Disagree

• Strongly Disagree

Now think about your experiences with all the services provided by the Department of Veterans Affairs (which include healthcare, benefits programs, or memorial services). Please tell us how you feel about the following statements:

9. “I got the service I needed.”

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

9. “It was easy to get the service I needed.”

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

VA Form 10-0481 December 2009

9. “I felt like a valued customer.”

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

9. “I trust VA to fulfill our country’s commitment to veterans.”

• Strongly Agree

• Agree

• Neither Agree or Disagree

• Disagree

• Strongly Disagree

VA Form 10-0481 December 2009