Form VA Form 10-0467 VA Form 10-0467 uSPEQ Consumer Experience Survey (Rehabilitation)

OMB Number 2900-0752
Estimated Burden: 5 minutes

ū•SPĒQ uSPEQ ū•SPĒQ

Consumer Experience Survey
(Rehabilitation)

The Paperwork Reduction Act of 1995 requires us to notify you that th is information collection is
in accordance with the clearance requirements of section 3507 of th e Paperwork Reduction Act of 1995.
The public reporting burden for this collection of info rmation is estimated to t ake five minutes for the
complete survey based on an average of 23 seconds per question, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Respondents should be awar e that notwithstanding any other
provision of law, no p erson shall b e subject to any penalty for failing to comply with a collection of
information if it does not di splay a currently valid OMB control number. Customer satisfaction surveys are
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 to shape the direction
and focus of specific, programs and services.
PRIVACY ACT STATEMENT
The information on this uSPEQ Consumer Experience Survey is requested by the Veterans Health
Administration to a ssess veteran's perception of satisfaction with VA rehabilitation and health care. Th e
information you supply will be confidential and protected by the Privacy Act of 1974 (5 U.S.C. 522a) and
the VA's confidentiality statute (38 U.S.C. 5701) as implemented by 38 CFR 1.526(a) and 38 CFR 1.576(b).
Disclosure of information involves release of statistical data and other non-identifying data for the
improvement of services within the VA rehabilitation and health care system and associated administrative
purposes. Participation is voluntary; failure to furnish the requested information will have no adverse effect
on any VA benefit to which you may be entitled.

VA Form 10-0467
DEC 2008