Form 012 2018 012 DHA Feedback Questions_ OMB Approval (1)
E-Government Website Customer Satisfaction Surveys
2018 012 DHA Feedback Questions_ OMB Approval (1).xlsx
2018 012 DHA Feedback Questions_ OMB Approval (1)
OMB: 1090-0008
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1090-0008 can be found here:
Document [xlsx]
Download: xlsx | pdf
| Model Name | ForeSee Feedback Questions | |||
| Date | 11/17/2016 FCG IA# 30605 | 
|
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| Question Text | Answer Choices | |||
| How do you rate your experience with the Defense Health Agency? | 1 Star | |||
| 2 Stars | ||||
| 3 Stars | ||||
| 4 Stars | ||||
| 5 Stars | ||||
| What is your feedback related to? | TRICARE Health Plan | |||
| Clinical Support | ||||
| Health Surveillance | ||||
| Immunizations | ||||
| Provider Rates and Reimbursements | ||||
| Other | ||||
| Please describe your experience with the Defense Health Agency. | ||||
| What is your beneficiary status? [Optional] | Uniformed Service member | |||
| Retired Service member | ||||
| Guard/Reserve member | ||||
| Family member | ||||
| DHA employee | ||||
| Other government employee | ||||
| Vendor/Contractor | ||||
| TRICARE network provider | ||||
| Other | ||||
| What is your region? [Optional] | East | |||
| West | ||||
| Overseas | ||||
| Don't Know | ||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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