VA Form 10-10072a SSVF Participant Satisfaction Survey

OMB Control Number: 2900-0757

Estimated Burden: 15 minutes

Expiration Date: XX/XX/XXXX

DEPARTMENT OF VETERANS AFFAIRS

SUPPORTIVE SERVICES FOR VETERAN FAMILIES (SSVF) PROGRAM

PARTICIPANT SATISFACTION SURVEY

Number of individuals (including yourself) in household receiving support services from this provider:

1 2 3 4+

Are you enrolled in the VA health care system?

Yes No

Were you enrolled in VA health care system prior to receiving services from this provider?

Yes No

1. How would you rate the quality of the services you have received from this supportive services provider?

Extremely Poor Below Average Average Above Average Excellent

2. Did the supportive services provider involve you in creating an individualized housing stabilization plan?

Yes No

4A. If you answered Yes to Question 5, do you feel that this housing plan is a good fit for your needs?

Yes No

3. In the following table, please indicate which supportive services you received and indicate the quality of the supportive services received.

Supportive Services	Did you need this service?	Did you receive this service?	What was the quality of service?
1. Case Management	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
2. Assistance in obtaining VA Benefits	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
3. Assistance in obtaining and coordinating other public benefits
a. Health care	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
b. Daily living	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
c. Personal financial planning	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
d. Transportation	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
e. Income support	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
f. Legal	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
g. Child care	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
h. Housing counseling	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
4. Other Supportive Services
a. Rental Assistance	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
b. Utility fee payment assistance	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
c. Security and utility deposits	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
d. Moving costs	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent
e. Purchase of emergency supplies	Yes No	Yes No	Extremely Poor	Below Average	Average	Above Average	Excellent

4. How many times have you moved since you started receiving services from this provider?

0. 1 2 3+

5. Since you started receiving services from this supportive services provider, was there a time when your income decreased so much that it became hard to pay your housing costs?

Yes No

6. How satisfied are you with the courteousness of the staff person that you initially spoke with when you contacted the provider? (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied)

7. How satisfied are you with the courteousness of the staff person that you dealt with most often while you were working with this provider? (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied)

8. How satisfied are you with the timeliness of communication with the staff person that you dealt with most often while you were working with this provider? (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied)

9. If your experiences were positive with this supportive services provider, please tell us why.

10. If your experiences were negative with this supportive services provider, please tell us why.

Please list any additional suggestions as to how to improve the SSVF Program.

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