Form 10-10058 Telephone Care Services Patient Satisfaction Survey

VISN 12 Telephone Care Services Satisfaction Survey

OMB No. 2900-0770
Estimated Burden: 10 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 10 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.

OMB 2900-0770
Estimated Burden: 10 minutes

William S. Middleton Memorial Veterans Hospital and Clinics

Telephone Care Services 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 10 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 currently 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 the development of needed improvements to the current VISN 12 Telephone Care Services 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.

For each item identified below, please circle the number best fits your level of satisfaction
with Telephone Care Services.

Courtesy

Courtesy of the nurse/clerk to whom you
spoke on the phone

Promptness

Promptness with which the telephone
was answered

If a return call was needed, degree to
which a nurse returned your call within
an acceptable amount of time

Listening

How well nurse listened to your concerns

Education

Understandability of the nurse’s advice

Usefulness of the information given by
the clerk

Other

Adequacy of time spent on phone with nurse

Degree to which staff identified themselves
to you

How well your needs were met by using
Telephone Care Services

Your likelihood of calling the Telephone
Care Services again

Overall service provided by the Telephone
Care Services

Comments:

10-10058

VA Form
MAR 2013

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good

1 very poor 2 poor  3 fair 4 good 5 very good