OMB 2900-0757
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
10-10072a
April 2011
OMB 2900-0757
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
10-10072a
April 2011
OMB Control Number:
Supportive Services for Veteran Families (SSVF) Program Participant Satisfaction Survey
Thank you for your willingness to complete this survey about the services you have received. Your responses will be
used by VA to better understand the effectiveness of the program and where services might be either kept the same, or
changed, to help other Veterans and their families. All answers you provide on this survey are confidential as survey
data does not include names.
Name of provider (Organization that provided you with SSVF Services):
1
2
3
4+
Number of individuals in household:
Yes
No
Are you enrolled in the VA health care system?
First
Second
Is this the first or second time completing this survey?
1. How would you rate the quality of the services you have received from this supportive services provider?
Poor
Average
Good
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. If you needed help again would you return to this supportive services provider?
Definitely Not
Probably Not
Probably So
Definitely
4. Did the supportive services provider involve you in creating an individualized housing stabilization plan?
Yes
No
4A. If you answered Yes to Question 5, do you feel that this housing plan is a good fit for your needs?
Yes
No
5. Is there any other feedback about the supportive services provider that you wish to provide to the VA?
6. In the following table, please indicate which supportive services you received and indicate the quality of the
supportive services received.
Did you receive
Did you need
What was the quality of the service?
Supportive Services
this service?
this service?
Yes
Yes
1. Case Management
No
No
Poor
Average
Good
Excellent
2. Assistance in
Yes
Yes
obtaining VA Benefits
No
No
Poor
Average
Good
Excellent
3. Assistance in obtaining & coordinating other public benefits
Yes
Yes
a. Health care
No
No
Poor
Average
Good
Excellent
Yes
Yes
b. Daily living
No
No
Poor
Average
Good
Excellent
c. Personal financial
Yes
Yes
planning
No
No
Poor
Average
Good
Excellent
d. Transportation
Yes
Yes
No
No
Poor
Average
Good
Excellent
Yes
Yes
e. Income support
No
No
Poor
Average
Good
Excellent
VA Form
10-10072a
4581649300
April 2011
Did you need
Did you receive
What was the quality of service?
this service?
this service?
Yes
Yes
f. Legal
No
No
Poor
Average
Good
Excellent
Yes
Yes
g. Child care
Poor
Average
Excellent
No
No
Good
Yes
Yes
h. Housing counseling
No
No
Poor
Average
Excellent
Good
4. Other Supportive Services
Yes
Yes
a. Rental assistance
No
No
Poor
Average
Good
Excellent
b. Utility fee payment
Yes
Yes
No
No
assistance
Poor
Average
Good
Excellent
c. Security and utility
Yes
Yes
No
No
deposits
Poor
Average
Good
Excellent
Yes
Yes
d. Moving costs
No
No
Poor
Average
Excellent
Good
e. Purchase of
Yes
Yes
No
No
emergency supplies
Poor
Average
Excellent
Good
Yes
Yes
f. Other:
No
No
Poor
Average
Excellent
Good
Please answer questions 7-10B 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.
7. Have you ever lived in one of the following places?
No On the street or a place not meant for human habitation
Yes
Yes
No In your car, boat, or an abandoned building
No Emergency shelter or drop-in center
Yes
No Transitional housing or halfway house
Yes
No Hotel/motel, Single Room Occupancy (SRO), Safe Haven
Yes
8. How many times did you move in the year before you requested help at this program?
0
1
2+
9. In the year before you requested help from this supportive services provider, was it sometimes hard to pay for housing due
to a change in income?
Yes
No
10. Did your employment status (employed full time, employed part time, unemployed) change significantly in the year before
you requested help from this supportive services provider?
Yes
No
10A. If you answered Yes to Question 11, did you start working or stop working?
Start Working
Stop Working
10B. If you answered No to Question 11, what is your employment status?
Employed full time
Employed part time
Unemployed
Please answer questions 11-13B 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 8-10B.
11. How many times have you moved since you started receiving services from this provider?
0
1
2+
12. Since you started receiving services was there a time when your income
decreased so much that it became hard to pay your housing costs?
Yes
No
13. 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
13A. If you answered Yes to Question 13, did you start working or stop working?
Start Working
Stop Working
13B. If you answered No to Question 11, what is your employment status?
Employed full time
Employed part time
Unemployed
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
10-10072a
April 2011
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