Sample_Bereavement_Survey_Letter_Inpatient.pdf

for

Thank you for taking the time to complete this survey.

Veterans near the end of their lives. We want to know if we are providing the best possible care to our Veterans and whether there is anything we could be doing better. Your opinions are important to us, so please tell us what you think. Your to participate, it will not a�ect your bene�ts in any way.

If you have any questions about the survey, please don’t hesitate to call us at the Veteran Experience Center on our toll-free number, 1-877-503-5817, and leave a message with your name, number, and reference «MergeID» and we will call you back as soon as possible.

THE OFFICE OF MANAGEMENT AND BUDGET HAS APPROVED THIS SURVEY UNDER OMB NUMBER 2900-

0701 IN ACCORDANCE WITH SECTION 3507 OF THE PAPERWORK REDUCTION ACT OF 1995. WE ESTIMATE

THAT IT WILL TAKE ABOUT 10 MINUTES TO ANSWER THESE QUESTIONS. YOUR RESPONSES WILL BE USED

TO MEASURE VETERANS’ AND THEIR FAMILIES’ PERCEPTIONS OF THE HEALTHCARE VA PROVIDES. YOUR

PARTICIPATION IS VOLUNTARY AND CONFIDENTIAL. IF YOU CHOOSE NOT TO PARTICIPATE, IT WILL NOT

AFFECT YOUR BENEFITS IN ANY WAY.

ESTIMATED TIME:

10 M I N U T E S

HOW TO FILL OUT THE SURVEY

• Please choose ONLY one answer per question.

• Please fill in each circle completely, like this:

Do not fill it like this:

• Do not write comments in the answer choice area. There are two open ended questions on page 4, please save any comments for those questions.

FIRST

PART

HOW TO SUBMIT THE SURVEY

• Once you have answered all the survey questions, tear along the dotted line on Page 3 to remove the survey from the booklet.

• Fold the survey into thirds and place it in the envelope provided.

• Seal the envelope and mail it.

SECOND

PART

Thank you again for providing the Veteran Experience Center with important feedback. Your answers will help ensure that all Veterans receive the high-quality care they deserve.

(e.g. returning medical supplies), you may:

• Contact your local VA medical center and ask to speak to the Patient Advocate.

For more information about , you may also:

Please call the Veteran Experience Center toll-free at 1-877-503-5817 and use the reference number on the first page of this packet if you:

• Need more information about bereavement services from the VA.

• Want to discuss additional concerns about the care the Veteran received.

• Prefer to complete the survey over the phone.

Thank you for your participation!

Call the VA O�ce of Survivors Assistance at 202-461-1077.

Visit the VA bene�ts web page at http://www.bene�ts.va.gov/bene�ts/

Call the VA bene�ts line toll-free at 1-800-827-1000.

Visit the VA O�ce of Survivors Assistance web page at http://www.va.gov/survivors/

CONTINUE TO QUESTION 11

SKIP TO QUESTION 12

1. First, please tell us how you are related to the Veteran. I am her:

Spouse Parent Child Sibling Other Relative

Ex-Spouse Friend Partner POA/Legal Guardian/Caretaker Other

2. During her last month of life, how much of the time were the staff who took care of her willing to take time to listen?

Always Usually Sometimes Never I did not speak to the staff who took care of her

3. During her last month of life, how often did the staff provide her with the medication and medical treatment that you and she wanted?

Always Usually Sometimes Never Unsure She did not receive any treatment

4. During her last month of life, how often were the staff who took care of her kind, caring, and respectful?

Always Usually Sometimes Never Unsure

5. During her last month of life, how often did the staff who took care of her keep you or other family members informed about her condition and treatment?

Always Usually Sometimes Never Unsure

6. Did anyone alert you or your family when she was about to die?

Yes No Unsure Her death was unexpected

7. From what you know about her time as an inpatient, how often do you think her personal care needs–such as bathing, dressing, and eating meals–were taken care of as well as they should have been?

8. In the last month of her life, did she have pain or did she take medicine for pain?

Yes No Unsure

9. How often did her pain make her uncomfortable?

Always Usually Sometimes Never Unsure She did not have any pain

10. Some Veterans near the end of life re-experience the stress and emotions that they had when they were in combat. Did this happen to her in the last month of life?

Yes No Unsure

11. How often did the stress make her uncomfortable?

Always Usually Sometimes Never Unsure She did not re-experience combat stress/emotions

12. In her last month of life, how much of the time did the staff who took care of her provide you and her with the kind of spiritual support you both would have liked?

Always Usually Sometimes Never We did not want or need any spiritual support

Always Usually Sometimes Never Unsure We did not want or need help with personal care

13. In her last month of life, how much of the time did the staff who took care of her provide you and her with the kind of emotional support you both would have liked prior to her death?

Always Usually Sometimes Never We did not want or need any emotional support

14. What about after her death - how much of the time did the staff who took care of her provide you with the kind of emotional support you would have wanted?

Always Usually Sometimes Never We did not want or need any emotional support

CONTINUE TO QUESTION 9

SKIP TO QUESTION 10

nursing assistants, therapists, and other personnel.

D E PA R T M E N T O F V E T E R A N S A F F A I R S S U R V E Y PAGE THREE

PLEASE CONTINUE ON THE BACK>

15. Would it have been helpful if the VA had provided more information about benefits for surviving spouses and dependents?

Yes No Unsure

16. Would it have been helpful if the VA had provided more information about burial and memorial benefits?

Yes No Unsure

17. Would it have been helpful if the VA had provided more help with her funeral arrangements?

Yes No Unsure

18. Overall, how would you rate the care that she received in the last month of her life?

Excellent Very Good Good Fair Poor

SUGGESTIONS & COMMENTS

D E PA R T M E N T O F V E T E R A N S A F F A I R S S U R V E Y PAGE FOUR

19. Is there anything else that you would like to share about the Veteran’s care during her last month of life?

20. Is there anything else that you would like to share about how the care could have been improved for the Veteran?

Unique ID#Thank you for completing our survey.