SORCC - Veterans Satisfaction Survey of Spiritual Care Needs

VA SORCC Chaplain Service/HBPC
Spiritual Needs Survey
OMB No. 2900-0770
Estimated Burden: 2 min.
Expiration Date: 9/30/2020

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 2 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
services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which
you may be entitled.

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Chaplain Service Spiritual Needs Evaluation
Jackson County Team

Date: ___________

Josephine County Team

Klamath County Team

Please tell us how you feel about the following statements:
“I believe I have spiritual concerns”
Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree _____ Agree _____ Strongly Agree _____

“My spiritual concerns are currently being addressed by the HBPC team.”
Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree _____ Agree _____ Strongly Agree _____

“My spiritual concerns are currently being addressed by local group/institution.”
Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree _____ Agree _____ Strongly Agree _____

if Agree or Strongly Agree, please check:
( ) Church ( ) Spiritual/Religious Group

( ) Family

( ) Myself

“If a VA Chaplain were available, I would like to discuss my spiritual concerns with them”
Strongly Disagree _____ Disagree _____ Neither Agree nor Disagree _____ Agree _____ Strongly Agree _____

Comments (Please include anything you think would be helpful for improving spiritual care or any
general comments):

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