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<h2>CCHT Patient Satisfaction Survey Version 2</h2>

<p class=MsoBodyText>“It is important to know what you think about the Home
Telehealth  program.  Please answer the following eight questions. The OMB
survey approval number is <b>2900-0766. </b>”</p>

<p class=MsoNormal>**Notes: </p>

<p class=MsoNormal style='margin-left:1.0in;text-indent:-.25in'>1.<span
style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>The
numbers in parentheses are how the response will be scored in the database.</p>

<p class=MsoBodyText style='margin:0in;margin-bottom:.0001pt'><span lang=ES
style='font-family:"Garamond","serif"'>&nbsp;</span></p>

<h3><a name="_Toc121723983"></a><a name="_Toc121722662"></a><a
name="_Toc121722249"><span style='font-size:16.0pt'>Home Telehealth Patient
Satisfaction Questionnaire Content</span></a><span style='font-size:16.0pt'>:</span></h3>

<p class=Default> <b><span style='font-size:11.5pt'>1. My care coordinator
explains things in a way that is easy to understand</span></b><span
style='font-size:11.5pt'>. </span></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Always (1)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Usually (2)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Sometimes (3)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Never (4)</span></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default><b><span style='font-size:11.5pt'>2. The information provided
by my care coordinator has helped me manage my health problem(s).</span></b></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Strongly Agree (1)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Agree (2)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Disagree (3)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Strongly Disagree (4)</span></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default><b><span style='font-size:11.5pt'>3. Over the past 3 months,
my home telehealth equipment works</span></b><span style='font-size:11.5pt'>: </span></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Always (1)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Usually (2)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Sometimes (3)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Never (4)</span></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default><b><span style='font-size:11.5pt'>4. My home telehealth
equipment is easy to use. </span></b></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Strongly Agree (1)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Agree (2)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Disagree (3)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Strongly Disagree (4)</span></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default><span style='font-size:10.0pt'>&nbsp;</span></p>

<p class=Default><b><span style='font-size:11.5pt'>5. I have made changes in
the way I take care of myself as a result of the VA home telehealth program. </span></b></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Strongly Agree (1)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Agree (2)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Disagree (3)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Strongly Disagree (4)</span></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default><b><span style='font-size:11.5pt'>6. When I have questions, I
am able to contact my care coordinator during business hours. </span></b></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Always (1)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Usually (2)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Sometimes (3)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Never (4)</span></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default><b><span style='font-size:11.5pt'>7. Using the VA home
telehealth program has made a positive difference in my health. </span></b></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Strongly Agree (1)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Agree (2)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Disagree (3)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Strongly Disagree (4)</span></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default><b><span style='font-size:11.5pt'>8. I would recommend a home
telehealth program to others. </span></b></p>

<p class=Default><span style='font-size:11.5pt'>&nbsp;</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Strongly Agree (1) </span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Agree (2)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Disagree Strongly (3)</span></p>

<p class=Default style='margin-left:.5in;text-indent:-.25in'><span
style='font-size:11.5pt;font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span><span style='font-size:11.5pt'>Disagree (4)</span></p>

<p class=MsoBodyText style='margin:0in;margin-bottom:.0001pt'>&nbsp;</p>

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