A-1 VA West “Veterans Affairs Survey”

Veteran VA Experience Feedback Survey

This form helps Veterans share their experiences with the VA. Please fill out honestly. Circle numbers from 1 (Bad) to 5 (Great).
1. About You
What branch did you serve in?
Where do you live?
Year of Separation?
What VA Clinic or Hospital did you go to?
2. Your VA Experience (Circle One for Each)
How easy was it to get help from the VA?

1

2

3

4

5

1 is Worst, 5 is Best
How fast did they respond to you?

1

2

3

4

5

1 is Worst, 5 is Best
Were the people you spoke with polite and respectful?

1

2

3

4

5

1 is Worst, 5 is Best
Did they help you with your claim or medical care?

1

2

3

4

5

1 is Worst, 5 is Best
Did you feel like they cared about you?

1

2

3

4

5

1 is Worst, 5 is Best
Could you reach someone in charge when needed?

1

2

3

4

5

1 is Worst, 5 is Best
Do you understand how to appeal a VA decision?

1

2

3

4

5

1 is Worst, 5 is Best
Overall, how would you rate your VA experience?

1

2

3

4

5

1 is Worst, 5 is Best
Did you understand the information they gave you?
How long did it take to hear back from the VA?
3. Your Thoughts
Tell us something good about your VA experience:
Tell us something that made you upset or confused:
If you could change one thing about the VA, what would it be?
Anything else you want to say?
4. Can We Contact You?
Can we contact you to ask more questions if needed?
Name (Optional)

First NameLast Name
Phone (Optional)
Please enter a valid phone number.Format: (000) 000-0000.
Email (Optional)
example@example.com
Should be Empty:

Veteran VA Experience Feedback Survey

1. About You

2. Your VA Experience (Circle One for Each)

3. Your Thoughts

4. Can We Contact You?