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VA Form 10-0508a SSVF Participant Satisfaction Survey
ICR 201110-2900-001 · OMB 2900-0757 · Object 27810801.
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OMB 2900-XXXX Estimated Burden 15 minutes Supportive Services for Veteran Families (SSVF) Program Participant Satisfaction Survey Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for completing and reviewing the collection of information. Respondents should be aware that notwithstanding any other provision of law, no person will be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Response to this survey is voluntary and failure to participate will have no adverse effect on benefits to which you might otherwise be entitled. VA Form April 2011 10-0508a OMB Control Number: Supportive Services for Veteran Families (SSVF) Program Participant Satisfaction Survey To assist VA in improving the SSVF Program, please complete this form and mail it back (postage pre-paid) / Date / Name of provider: Number of individuals in household: 1 2 3 4+ Number of individuals in household receiving support services from this provider: Yes No Are you enrolled in the VA health care system? Is this the first or second time completing this survey? First 1 2 3 4+ Second 1. How would you rate the quality of the services you have received from this supportive services provider? Extremely Poor Below Average Average Above Average Excellent 2. If another Veteran or a friend were in need of similar help, would you recommend this supportive services provider to him or her? Definitely Not Probably Not Probably So Definitely 3. How satisfied are you with the services you have received from this supportive services provider? Very Dissatisfied Dissatisfied Neither Satisfied Nor Dissatisfied Satisfied Very Satisfied 4. If you needed help again and had a choice of where to go at no cost to you, would you return to this supportive services provider? Definitely Not Probably Not Probably So Definitely 5. Did the supportive services provider involve you in creating an individualized housing stabilization plan? Yes No 6. If you answered Yes to Question 5, do you feel that this housing plan is a good fit for your needs? Yes No 7. Is there any other feedback about the supportive services provider that you wish to provide to the VA? 8. In the following table, please indicate which supportive services you received and indicate the quality of the supportive services received. Supportive Services 1. Case Management 2. Assistance in obtainng VA Benefits Did you need this service? Yes No Yes No Did you receive What was the quality of the service? this service? Yes No Extremely Poor Below Average Average Above Average Yes No Extremely Poor Excellent Below Average Average Above Average Excellent 3. Assistance in obtaining & coordinating other public benefits a. Health care Yes No Yes No Extremely Poor Below Average Average Above Average Excellent b. Daily living Yes No Yes No Extremely Poor Below Average Average Above Average Excellent c. Personal financial planning Yes No Yes No Extremely Poor Below Average Average Above Average Excellent d. Transportation Yes No Yes No Extremely Poor Below Average Average Above Average Excellent Yes No Yes No Extremely Poor Below Average Average Above Average Excellent e. Income support VA Form April 2011 10-0508a 4581649300 Did you need this service? Yes No Yes No f. Legal g. Child care h. Housing counseling Did you receive this service? Yes Extremely Poor No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No What was the quality of service? Below Average Average Above Average Excellent Extremely Poor Below Average Average Above Average Excellent Extremely Poor Below Average Average Above Average Excellent Extremely Poor Below Average Average Above Average Excellent Extremely Poor Below Average Average Above Average Excellent Extremely Poor Below Average Average Above Average Excellent Extremely Poor Below Average Average Above Average Excellent Extremely Poor Below Average Average Above Average Excellent Extremely Poor Below Average Average Above Average Excellent 4. Other Supportive Services a. Rental assistance b. Utility fee payment assistance c. Security and utility deposits d. Moving costs e. Purchase of emergency supplies f. Other: Please answer questions 9 - 14 if you have recently begun receiving services from this provider. You do not need to answer these questions if this is the second time you are completing this survey. 9. Have you ever lived in one of the following places? Yes Yes Yes Yes Yes No On the street or a place not meant for human habitation No In your car, boat, or an abandoned building No Emergency shelter or drop-in center No Transitional housing or halfway house No Hotel/motel, Single Room Occupancy (SRO), Safe Haven Yes No In a family or friend's apartment or house because you had nowhere else to go 10. If you answered Yes to any of the places listed in Question 9, on how many separate occasions did you sleep in one of those places? 1 time 2-5 times 6-10 times More than 10 times 11. How many times did you move in the year before you requested help at this program? 0 1 2 3+ 12. In the year before you requested help from this supportive services provider, was there a time when your income decreased so much that it became hard to pay your housing costs? Yes No 13. Did your employment status (employed full time, employed part time, unemployed) change significantly in the year before Yes No you requested help from this supportive services provider? 14. If you answered Yes to Question 13, did you start working or stop working? Start Working Stop Working Please answer questions 15 - 18 if you are no longer receiving services from this provider or will no longer be receiving services from this provider in the immediate future. You do not need to answer these questions if you answered questions 9-14. 15. How many times have you moved since you started receiving services from this provider? 0 1 2 3+ 16. Since you started receiving services from this supportive services provider, was there a time when your income decreased so much that it became hard to pay your housing costs? Yes No 17. Has your employment status changed significantly (employed full time, employed part time, unemployed) since you started receiving services from this supportive services provider? Yes No 18. If you answered Yes to Question 17, did you start working or stop working? Start Working Stop Working Please place your completed survey in the envelope provided, seal the envelope and return it in accordance with the instructions you were given at the time you received the survey. Do not place your name on this survey or on the envelope. Thanks for your feedback. If you have any questions, please feel free to contact the SSVF Program Office at 1-877-737-0111 or via e-mail at SSVF@va.gov or visit http://www.va.gov/homeless/ssvf.asp. VA Form 6422649306 April 2011 10-0508a
| File Type | application/pdf |
| File Title | SSVF Participant Satisfaction Survey 3.24.11 (64930 - Draft, VersiF |
| Author | VHAPHIGRAYDM |
| File Modified | 2011-04-13 |
| File Created | 2011-04-11 |