Form 2020-2900-0876-R1 Clinical Contact Center Survey

VA Pharmacy line
VA RN Triage line
VA Scheduling and General Inquiries line
VA Telehealth Provider

Clinical Contact Center Professional
VA Telehealth Provider

CCC Survey

DRAFT <06/16/20>
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) 273-8255 (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: 4 minutes

Help us serve you better
We want to hear about your recent interaction with [the VA call center or
a VA agent]. 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 4 minutes to complete.
I waited a reasonable amount of time to speak to a [agent]. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

It was easy to reach the right person about my need. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

The [agent] took a reasonable amount of time to address my need. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I understood the information provided by the [agentl]. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

The [agent] I interacted with was helpful. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

The issue that I contacted the [Contact Center Name] about on [date/today] was
resolved. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I am satisfied with the service I received from [Call Center Name]. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I trust VA to fulfill our country's commitment to Veterans. 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 interaction with the ?
Please select from one of the following options.
Select your response
[ Insert Logic ]

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.

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

Next
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

LIP Specific
Provider Survey

DRAFT <06/16/20>
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) 273-8255 (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: 4 minutes

Help us serve you better
We want to hear about your recent interaction with a VA telehealth
provider. 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 4 minutes to complete.
I am satisfied with the care I received during this interaction / appointment over the
phone. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

It was easy to reach the right person about my need. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

The issue that I contacted the VA Telehealth Provider about on [Month DD, YYYY] was
addressed. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I understood the information provided by the VA Telehealth Provider. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

After my virtual visit, I knew what I needed to do next. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I waited a reasonable amount of time to speak to a VA Telehealth Provider. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

The VA Telehealth Provider took a reasonable amount of time to address my need.
Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I trust VA to fulfill our country's commitment to Veterans. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

If you sought a telehealth appointment at VA, tell us the main reason why. Required
I did not want to go to VA in-person because of COVID-19 concerns.
I was given the option to have a telehealth appointment because it would meet my care needs.
Other

Would you like to provide additional feedback with a concern, compliment, or
recommendation about your interaction with the ?
Please select from one of the following options.
Select your response
[ Insert Logic ]

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.

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

Next

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

DRAFT <06/16/20>
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) 273-8255 (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: 4 minutes

Help VA improve its services.
We are working to better understand our customers. The following
questions are voluntary. By providing your data, your responses can help
us improve VA care and services. Thank you for your participation.
Are you Hispanic or Latino?
Yes
No

How would you describe your race? Please select all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

How would you describe your gender?
Male
Female
Non-Binary/ Third Gender
Prefer not to say
Finish

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

DRAFT <06/16/20>
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) 273-8255 (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: 4 minutes

Thank you for choosing VA.
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously to improve your experience with
VA services.
Please visit VA.gov to explore benefits, resources, and information
at 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. 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 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. 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

CCC Survey - Initial Email

DRAFT <06/16/20>
Working Draft, Pre-Decisional, Deliberative document - Internal VA Use Only

EMAIL SUBJECT LINE: [Call Center Name] Experience Survey
EMAIL PREHEADER: Tell us about your interaction with the [Call Center Name]

OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 4 minutes

Your opinion matters
Dear ,
We care about your experience with VA. Please take this 4
minute survey to let us know about your interaction on
[Month DD, YYYY] with the [Call Center Name]. The more
information you share with us, the better we can serve you.

Take Our Survey

Thank you,
Veterans Experience Office
Department of Veterans Affairs

Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 1 (800) 273-8255 (Press 1), or text 838255 to receive confidential support 24/7
(System of Records Notice VA158VA10NC5). Visit https://www.veteranscrisisline.net for
more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.

Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
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.

CCC Survey - Follow up Email

DRAFT <06/16/20>
Working Draft, Pre-Decisional, Deliberative document - Internal VA Use Only

EMAIL SUBJECT LINE: [Call Center Name] Experience Survey
EMAIL PREHEADER: We still want to hear about your interaction with the [Call Center Name]

OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 4 minutes

Your feedback is important to us
Dear John Smith,
VA still wants to hear about your interaction on [Month DD,
YYYY] with the [Call Center Name]. Please let us know
how we are doing by taking a 4 minute survey regarding
your experience.
Take Our Survey

Thank you,
Veterans Experience Office
Department of Veterans Affairs

Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 1 (800) 273-8255 (Press 1), or text 838255 to receive confidential support 24/7
(System of Records Notice VA158VA10NC5). Visit https://www.veteranscrisisline.net for
more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.

Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
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.

Provider Survey - Initial Email

DRAFT <06/16/20>
Working Draft, Pre-Decisional, Deliberative document - Internal VA Use Only

EMAIL SUBJECT LINE: [Call Center Name] Experience Survey
EMAIL PREHEADER: Tell us about your interaction with the [Call Center Name]

OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 4 minutes

Your opinion matters
Dear ,
We care about your experience with VA. Please take this 4
minute survey to let us know about your interaction on
[Month DD, YYYY] with a VA Telehealth Provider. The
more information you share with us, the better we can
serve you.

Take Our Survey

Thank you,
Veterans Experience Office
Department of Veterans Affairs

Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 1 (800) 273-8255 (Press 1), or text 838255 to receive confidential support 24/7
(System of Records Notice VA158VA10NC5). Visit https://www.veteranscrisisline.net for
more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.

Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
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.

Provider Survey - Follow up Email

DRAFT <06/16/20>
Working Draft, Pre-Decisional, Deliberative document - Internal VA Use Only

EMAIL SUBJECT LINE: [Call Center Name] Experience Survey
EMAIL PREHEADER: We still want to hear about your interaction with a VA telehealth provider.

OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 4 minutes

Your feedback is important to us
Dear John Smith,
VA still wants to hear about your interaction on [Month DD,
YYYY] with a VA Telehealth Provider. Please let us know
how we are doing by taking a 4 minute survey regarding
your experience.
Take Our Survey

Thank you,
Veterans Experience Office
Department of Veterans Affairs

Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 1 (800) 273-8255 (Press 1), or text 838255 to receive confidential support 24/7
(System of Records Notice VA158VA10NC5). Visit https://www.veteranscrisisline.net for
more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.

Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
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.