Home Health Care Services Satisfaction Questionnaire

OMB 2900-0770
Estimated Burden: 5 min.

HOME HEALTH CARE SERVICE SATISFACTION SURVEY

OMB No. 2900-0770
Estimated Burden: 5 minutes

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

HOME HEALTH CARE SERVICE SATISFACTION SURVEY

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 5 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Customer satisfaction surveys are 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 helping to shape the direction and focus of specific programs and services. 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.

Check box:	Strongly Agree	Agree	N/A	Disagree	Strongly Disagree
The following statements refer to your level of satisfaction with the Home Health Agency services/staff and completed by the Veteran or their Caregiver:
1.Veteran is receiving services from a Home Health Agency as ordered by the physician:
2. Veteran/Caregiver is satisfied with the care provided by the agency provider/nurse aide:
3. Veteran and/or Caregiver is satisfied with care provided by the home health agency’s license nurse:
4. Veteran and/or Caregiver is satisfied with care provided by the home health agency’s physical therapist or occupational therapist:
5. What is our level of satisfaction with the agency’s office staff:
	Poor	Fair	Good	Very Good	Excellent
6. How would you rate your overall satisfaction with Home Health services? Comments: