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pdfThe VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless or
at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 2 minutes
Help us serve you better
We want to hear about your recent inpatient stay at . By
indicating how much you agree or disagree with the statements below,
you directly help us improve VA services.
This survey should take you approximately 2 minutes to complete.
The staff was helpful when I settled into my hospital room. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I understood what care I would receive while I was in the hospital. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
The hospital provided things for me to do in my down time (TV, internet,
reading materials, etc.). Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
My care team was there for me when I needed them. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
When I was notified that I would be leaving the hospital, it was clear what
needed to be done and how much time it would take. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
Efforts were made to have my family, friends, or caregivers involved in the
explanation of my discharge instructions, when desired. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
The instructions that I received before I left the hospital were easy to
understand. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I understood my transportation options before I left the hospital. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I was satisfied with the care I received in the hospital. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I trust to fulfill our country’s commitment to Veterans and
their families. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your most recent inpatient experience at ?
Please select from one of the following options. Required
Select your response
Use the text box below to provide details about your experience. Please do not
include any personally identifiable information, Social Security Number, Veteran ID, or
medical information.
0/400
Can VA contact you about your feedback? Required
Yes, VA can contact me about my experience.
No, I do not want VA to contact me about my experience.
Finish
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. This
information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of two minutes to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 2738255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless or
at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 4243838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 29000770
Expiration: 09/30/2020
Estimated Burden: 2 minutes
Thank you for choosing VA
The U.S. Department of Veterans Affairs uses these surveys to
collect your feedback in order to continuously improve your
experience with VA services.
Please visit VA.gov to explore benefits, resources, and information
at VA.
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. This
information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of two minutes to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will
have no impact on VA benefits or services to which you may currently be receiving. By filling out this survey, you are
authorizing VA database access to retrieve veteran contact information to follow up with you accordingly for purposes of
service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA.
VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
Privacy Policy
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |