VA Loma Linda Healthcare System CBOC Clinics - Patient Satisfaction Survey

VA Loma Linda Healthcare System CBOC Clinics

Patient 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 survey will lead to improvements in the quality of service delivery by helping staff to shape the direction and focus of services and the patient experience.

Privacy Act Statement: Participation in this survey is voluntary, and failure to respond will have no impact on benefits to which you may be entitled. If you choose to include your name, it will be kept confidential and private to the extent provided by law.

OMB Control Number:  2900-0770

Estimated Burden:  5 minutes

Expiration Date:  09/30/2020

VA Loma Linda Healthcare System CBOC Clinics

Patient Survey for __________________________

Date of Visit _________________

Which PACT Team Provider did you meet with today? __________________________________

1. How long did you wait to be seen by your provider after your scheduled time?

<15 minutes 15-30 minutes >30 minutes

Rating Scale:

1 – Very Dissatisfied 2 – Dissatisfied 3 – Neutral 4 – Satisfied 5 – Very Satisfied

2. How would you rate the courtesy and help of our Front Desk and Support staff?

1 2 3 4 5

3. How would you rate the care you received from our Nursing Staff today?

1 2 3 4 5

5. How would you rate the care you received from your PACT Team Provider?

1 2 3 4 5

6. How would you rate the ease to contact the clinic and/or provider by Phone or Secure Messaging ?

1 2 3 4 5

7. Anyone you would like to thank today?__________________________________

8. Is there anything we can do to improve?

Name* (Optional) ____________________________________________________

[*Please note that, by providing your name, VA may attempt contact you regarding your survey responses. This is only an effort to improve experiences in the CBOC clinics, and you may decline to respond if contacted by VA.]

Comments concerning the accuracy of the burden estimate and any suggestions for reducing this burden should be sent to Alicia Garcia, CBOC Director, email: Alicia.Garcia@va.gov .