Form 2900-0876-ATLAS Su 2900-0876-ATLAS Su 2900-0876-ATLAS Survey Wireframes

Telehealth ATLAS
V5 DRAFT
09/08/21
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: 5 minutes

Help us serve you better
We want to hear about your ATLAS (Accessing Telehealth through Local
Area Stations) experience. 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 5 minutes to complete.
I trust Telehealth as part of my overall VA healthcare. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I found it easy to schedule my ATLAS (Telehealth) appointment. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

Connecting to my video appointment was easy. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

When connecting to my appointment, I felt confident using the technology provided.
Required
Strongly
Neither Agree
Strongly
Disagree
Agree
Disagree
nor Disagree
Agree
1

2

3

4

5

During my appointment, my provider made me feel at ease by explaining every step they
took and in a way that was easy to understand. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

After my appointment, I was clear about my next steps of care. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

ATLAS (Telehealth) reduces the need to travel long distances in order to meet with my
provider. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I was able to see the provider clearly by video. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I was able to hear the provider clearly by video. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

At the beginning of the video visit, the provider addressed privacy concerns.
Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I would recommend ATLAS (Telehealth) to other Veterans. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

Overall, I am satisfied with the video telehealth visit. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I felt the space provided at this location gave me privacy. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

I would recommend this ATLAS (Telehealth) location as a place for VA care to a fellow
Veteran. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

When you consider your options for the ATLAS (Telehealth) appointment you just had,
which do you prefer? Required
Video visit
Phone visit
In-person visit

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 5 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

Telehealth ATLAS
V5 DRAFT
09/08/21
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: 5 minutes

Thank you for your choosing VA
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously 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. 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 5 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