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pdfC&P Exam Visit Survey
V2.0 01/15/19
Working Draft, Pre-Decisional, Deliberative Document - Internal VA Use Only
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: 1 minute
Help us serve you better
We want to hear about your recent healthcare visit.
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 1 minute to complete.
After I entered , I found it easy getting to my appointment.
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
After I checked in for my appointment, I knew what to expect.
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
My examiner listened carefully to me. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
My examiner explained things in a way that I could understand.
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
After my visit, I knew what I needed to do next.
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I am satisfied with the service I received from . 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
Can VA contact you about your feedback? Required
Yes, VA can contact me about my patient experience.
No, I do not want VA to contact me about my patient experience.
Would you like to volunteer your demographic information to help VA better
serve you?
Yes
No
Next
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 one minute 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 https://www.reginfo.gov/public/do/PRAMain.
Privacy Policy
C&P Exam Visit Survey
V2.0 01/15/19
Working Draft, Pre-Decisional, Deliberative Document - Internal VA Use Only
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: 1 minute
We are working to better understand our customers. The following
questions are voluntary.
Are you Hispanic or Latino?
Yes
No
How would you describe your race? Select all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Finish
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 one minute 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 https://www.reginfo.gov/public/do/PRAMain..
Privacy Policy
C&P Exam Visit Survey
V2.0 01/15/19
Working Draft, Pre-Decisional, Deliberative Document - Internal VA Use Only
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: 1 minute
Thank you for your 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.
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 one minute 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 https://www.reginfo.gov/public/do/PRAMain.
Privacy Policy
C&P Exam - Appointment Survey
V2.0 01/15/2019
Working Draft, Pre-Decisional, Deliberative Document - Internal VA Use Only
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: 1 minute
Help us serve you better
We want to hear about your recent appointment 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 1 minute to complete.
It was easy to get my appointment.
Strongly
Disagree
1
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
2
3
4
5
I got my appointment on a date and time that worked for me. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
When scheduling my appointment, I was treated with courtesy and respect.
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly Agree
1
2
3
4
5
I am satisfied with the service I received from . 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
Can VA contact you about your feedback? Required
Yes, VA can contact me about my patient experience.
No, I do not want VA to contact me about my patient experience.
Would you like to volunteer your demographic information to help VA better
serve you?
Yes
No
Next
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 one minute 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 https://www.reginfo.gov/public/do/PRAMain.
Privacy Policy
C&P Exam - Appointment Survey
V2.0 01/15/2019
Working Draft, Pre-Decisional, Deliberative Document - Internal VA Use Only
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: 1 minute
We are working to better understand our customers. The following
questions are voluntary.
Are you Hispanic or Latino?
Yes
No
How would you describe your race? Select all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Finish
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 one minute 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 https://www.reginfo.gov/public/do/PRAMain.
Privacy Policy
C&P Exam - Appointment Survey
V2.0 01/15/2019
Working Draft, Pre-Decisional, Deliberative Document - Internal VA Use Only
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: 1 minute
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
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 one minute 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 https://www.reginfo.gov/public/do/PRAMain.
Privacy Policy
| File Type | application/pdf |
| File Modified | 2019-12-09 |
| File Created | 2019-12-09 |