Fillable Printable VA Form 10-10072a
Fillable Printable VA Form 10-10072a
VA Form 10-10072a
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
April 2011
10-10072a
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.
YesNo
YesNo
4A. If you answered Yes to Question 5, do you feel that this housing plan is a good fit for your needs?
4. Did the supportive services provider involve you in creating an individualized housing stabilization plan?
Definitely NotProbably NotProbably SoDefinitely
3. If you needed help again would you return to this supportive services provider?
Definitely NotProbably NotProbably SoDefinitely
2. If another Veteran or a friend were in need of similar help, would you recommend this supportive services
provider to him or her?
PoorAverageGoodExcellent
1. How would you rate the quality of the services you have received from this supportive services provider?
Number of individuals in household:
1
2
3
4+
Are you enrolled in the VA health care system?
YesNo
Is this the first or second time completing this survey?
First
Second
PoorAverage
Good
Excellent
PoorAverage
Good
Excellent
What was the quality of the service?
Did you receive
this service?
Yes
No
Yes
No
Supportive Services
1. Case Management
2. Assistance in
obtaining VA Benefits
3. Assistance in obtaining & coordinating other public benefits
a. Health care
Yes
No
PoorAverage
Good
Excellent
b. Daily living
Yes
No
PoorAverage
Good
Excellent
c. Personal financial
planning
Yes
No
PoorAverage
Good
Excellent
d. Transportation
Yes
No
PoorAverage
Good
Excellent
e. Income support
Yes
No
PoorAverageGoodExcellent
VA Form
April 2011
OMB Control Number:
10-10072a
4581649300
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):
Did you need
this service?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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 [email protected] or visit //www.va.gov/homeless/ssvf.asp.
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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?
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?
YesNo
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?
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?
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
13A. If you answered Yes to Question 13, did you start working or stop working?
No
YesNo
01
2+
YesNo
4. Other Supportive Services
f. Other:
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.
Yes
7. Have you ever lived in one of the following places?
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
h. Housing counseling
Yes
No
PoorAverage
Good
Excellent
PoorAverage
Good
Excellent
PoorAverage
Good
Excellent
Yes
No
Yes
No
g. Child care
f. Legal
Did you receive
this service?
What was the quality of service?
Yes
No
PoorAverage
Good
Excellent
e. Purchase of
emergency supplies
Yes
No
PoorAverage
Good
Excellent
d. Moving costs
Yes
No
PoorAverage
Good
Excellent
c. Security and utility
deposits
Yes
No
PoorAverage
Good
Excellent
b. Utility fee payment
assistance
Yes
No
PoorAverage
Good
Excellent
a. Rental assistance
Yes
No
PoorAverage
Good
Excellent
VA Form
April2011
10-10072a
6422649306
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10A. If you answered Yes to Question 11, did you start working or stop working?
10B. If you answered No to Question 11, what is your employment status?
Employed full time Employed part time Unemployed
8. How many times did you move in the year before you requested help at this program?
01
2+
Did you need
this service?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
13B. If you answered No to Question 11, what is your employment status?
Employed full time Employed part time Unemployed
