Form 10-0531 Childcare Services Satisfaction Survey

Veterans Health Administration

Childcare Services Satisfaction Survey

VA Form 10-0531

OMB 2900-0770
Estimated Burden: 1 minute

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 1 minute. 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 survey will lead to improvements in the quality of service delivery by VHA Childcare Services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

CHILDCARE SERVICES SATISFACTION SURVEY DATE ______________

Thank you for allowing us to provide care for your child today. Your feedback is very important to us. It will help us identify areas where we can improve our service, and to better understand your needs. Please take a moment to fill out the form below.

For each aspect of childcare listed below, please tell us the amount of improvement needed:
	None	Some	A Lot	Comments:
Cleanliness of the childcare facility
Safety of the equipment, activities, toys
Security of the childcare facility
Child/staff ratio
Convenience / location of service
Staff courtesy
Staff competency

2. I am this child’s/children’s:

• Mother/stepmother

• Father/stepfather

• Grandparent

• Legal guardian

• Other (please specify) _____________________

3. If this service were not available to me today, I would have:

• Made other arrangements for childcare

• Brought child/children with me to my
  appointment

• Cancelled or rescheduled my appointment

• Missed my appointment (no show)
  
  

4. Have you ever used childcare here before?

• Yes

• No (Skip to item 6)

5. If yes, how many times in the 3 last months?

• Didn’t use this service in the 3 last months

• 1 – 2 times

• 3 – 5 times

• More than 5 times

6. Do you plan to use this service again?

• Yes

• No (Please tell us why below)

• Maybe

7. How satisfied are you with the care provided to your child/children today?

• Very satisfied

• Satisfied

• Dissatisfied (Please tell us why below)

• Very dissatisfied (Please tell us why below)

We welcome your suggestions and comments! Please use the space provided below:

OMB 2900-0770

VA Form 10-0531