2900-0876-AB5 Telemedicine Store Forward At Home or Mobile Appointment

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 htt(;1s://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 htt(;1s://www.va.gov/HOMELESS/.

0MB N umber: 2900-0876
Expiration: 09/30/2023
Estimated Burden: 2 minutes

Help us serve you better
We want to hear about your recent Telehealth experience submitting photos or
information on your mobile device. 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.

I found using my mobile device to capture my image or information to be an easy
experience. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

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4

5

I felt comfortable with using my mobile device to capture my image or information.
Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

The VA staff was helpful when showing me how to set up the tablet or app on my mobile
device. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

After submitting my image or information, it was clear to me when I would expect my
results. Required
Strongly Disagree

Disagree

Neither Agree nor
Disagree

Agree

Strongly Agree

1

2

3

4

5

I trust Telehealth as part of my overall VA healthcare. Required