2900-0876-07B Covid-19 Post-Visit Survey

VA Survey

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) 424-3838 or visiting
https://www.va.gov/HOMELESS/.

OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 3 minutes

Help us serve you better.
We want to hear about your recent [Facility Name] healthcare visit on [Date]
which was during the COVID-19 pandemic. By answering the following
questions, you directly help us improve VA services.

This survey should take you approximately 3 minutes to complete.

The screening procedures while entering the VA facility made me feel safe.
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

I observed my health care team using hand sanitizer and/or proper hand washing
procedures.
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

https://survey.sbx.voice.va.gov/?a83f26a225c7261355e0e0f4c6d809b4-va-post-in-person-visit-v5[6/15/2020 3:17:11 PM]

Strongly Agree

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1

2

3

4

5

My health care team connected on a personal level and made me feel valued while
social distancing.
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

The cleanliness of the facility met my expectations for a safe health care environment.
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

I trust [Facility Name] to provide safe health care. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

https://survey.sbx.voice.va.gov/?a83f26a225c7261355e0e0f4c6d809b4-va-post-in-person-visit-v5[6/15/2020 3:17:11 PM]

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Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience(s) with [Facility Name]? Please select from
one of the following options. Required
- Select your response -

Use the text box below to enter details of the additional feedback (optional). Please do
not include any personally identifiable information, Social Security Number, Veteran
ID, or medical information, but do provide details about your experience.

0 / 400

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.

Are you aware of the virtual care options (video Telehealth visit, phone visit) that VA
offers?
Yes
No

https://survey.sbx.voice.va.gov/?a83f26a225c7261355e0e0f4c6d809b4-va-post-in-person-visit-v5[6/15/2020 3:17:11 PM]

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When you consider your options for your care, do you prefer a video Telehealth visit,
phone visit, or in-person visit?
Video Telehealth
Phone
In-Person
No Preference

Would you like to volunteer your demographic information to help VA better serve
you?
Yes
No

Next
Next

We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. 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 may utilize individual
Veteran survey data from this survey or other sources to ensure the final scores truly and accurately represent the experiences of
Veterans. 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 3 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 which you may
currently be receiving. 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. Information gathered will be kept private to the extent provided by law.

Privacy Policy

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