Paperwork Reduction Act notice
States OMB number 2900-0750, an average time of 5 minutes, and that submission is voluntary and has no impact on benefits.
10-10065
Ethics Consultation Feedback Tool
- Agency
- VA
- Revision
- May 2016
- Fillable fields
- 85
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10065: Ethics Consultation Feedback Tool
VA Form 10-10065 is the U.S. Department of Veterans Affairs Ethics Consultation Feedback Tool. It is a one-page survey for someone who recently spoke with the Ethics Consultation Service. The form says the service helps patients, families and staff work through ethical concerns by listening to what everyone thinks and helping people decide the best thing to do.
The survey asks the respondent to rate the ethics consultants on a five-point scale, say whether the service made recommendations and whether they were followed, and add comments. The form says submitting it is voluntary and that not responding has no impact on benefits.
You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-10065
Introduction and directions
Explains what the Ethics Consultation Service does and asks for an X in the box that best describes the most recent experience. NA means Not Applicable.
Rating the ethics consultants
Twelve statements, such as making you feel at ease, being an expert in ethics, describing possible options and being timely, plus an overall rating, each scored Excellent, Very Good, Good, Fair, Poor or N/A Don't Know.
Recommendations questions
Whether the consultation service made any recommendations and, if yes, whether they were generally followed, each answered Yes, No or Don't Know.
Comments and suggestions
Open space for any comments or suggestions for the Ethics Consultation Service.
How to fill out VA Form 10-10065
- 1
Think of the most recent consultation
The directions ask about your most recent experience with the Ethics Consultation Service.
- 2
Rate each statement
Place an X in one box per row, from Excellent to Poor, or N/A Don't Know when a statement does not apply.
- 3
Answer the recommendations questions
Mark Yes, No or Don't Know for whether recommendations were made and whether they were generally followed.
- 4
Add comments
Write any comments or suggestions in the space at the bottom of the page.
Why fill Form 10-10065 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Returning the survey
Where to return it
The form and VA's form page do not print a mailing address, fax number or online way to return it.
Voluntary
The form says submission is voluntary and that failure to respond will have no impact on benefits to which you may be entitled.
Edition
The edition is dated MAY 2016. The form carries OMB number 2900-0750 and an estimated burden of 5 minutes.
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Who uses VA Form 10-10065?
The form is addressed to people who recently spoke with someone from the Ethics Consultation Service.
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Questions about Form 10-10065
What is VA Form 10-10065?
It is the Ethics Consultation Feedback Tool, a one-page survey about a recent experience with VA's Ethics Consultation Service.
Who fills it out?
The form is addressed to someone who recently spoke with someone from the Ethics Consultation Service, which it says helps patients, families and staff work through ethical concerns.
Is filling it out required?
No. The form says submission is voluntary and that failure to respond will have no impact on benefits.
How long does it take?
The form says VA anticipates it will take an average of 5 minutes, including reading the instructions.
What rating scale does the form use?
Each statement is rated Excellent, Very Good, Good, Fair or Poor, with an N/A Don't Know column. The form says NA means Not Applicable.