Provider and household
The name of the provider, the number of individuals in the household (1, 2, 3 or 4+), whether you are enrolled in the VA health care system, and whether this is the first or second time completing the survey.
10-10072A
Supportive Services for Veteran Families (SSVF) Program—Participant Satisfaction Survey
- Agency
- VA
- Revision
- April 2011
- Fillable fields
- 191
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10072A: SSVF Program Participant Satisfaction Survey
VA Form 10-10072A is the U.S. Department of Veterans Affairs Supportive Services for Veteran Families (SSVF) Program Participant Satisfaction Survey. It asks people who received SSVF services about the provider that served them. The survey says VA will use the responses to better understand the effectiveness of the program and where services might be kept the same or changed to help other Veterans and their families.
The form is three pages. Page 1 is a cover with the Paperwork Reduction Act notice. The survey then asks about the provider and household, rates the provider, lists supportive services in a table, and ends with two sets of housing and employment questions: one for people who recently began receiving services and one for people no longer receiving them.
The form says the survey is voluntary. 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 10-10072A
Questions 1 to 5: the provider
The quality of services, whether you would recommend the provider or return to it, whether it involved you in an individualized housing stabilization plan and if that plan fits your needs, and any other feedback for VA.
Question 6: services table
For each service, whether you needed it, whether you received it and its quality. It covers case management, help obtaining VA benefits and other public benefits, and other supportive services such as rental assistance, utility fee payment assistance, deposits, moving costs and emergency supplies.
Questions 7 to 10B: recently began
Places you have lived, such as the street, a car, an emergency shelter or transitional housing, how many times you moved in the prior year, trouble paying for housing due to a change in income, and changes in employment.
Questions 11 to 13B: leaving services
How many times you moved since services started, whether income dropped so much that housing costs became hard to pay, and changes in employment status.
How to fill out VA Form 10-10072A
- 1
Name the provider
Write the organization that provided your SSVF services and answer the household questions.
- 2
Rate the provider
Answer questions 1 to 5 by marking a box for each, and add any other feedback in question 5.
- 3
Complete the services table
Mark whether you needed and received each service and rate its quality.
- 4
Answer the set that fits
The form says questions 7 to 10B are for people who recently began receiving services, and questions 11 to 13B for people no longer receiving services or who soon will not be.
Why fill Form 10-10072A 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 it and getting help
Return
The form does not print a return address or say where to send the completed survey.
Questions
The form lists the SSVF Program Office at 1-877-737-0111, by e-mail at [email protected], and the page http://www.va.gov/homeless/ssvf.asp.
Confidentiality
The form says all answers are confidential as survey data does not include names.
Edition
The footer reads VA Form April 2011 10-10072a. The cover lists OMB 2900-0757 and an estimated burden of 15 minutes.
Related forms
10-10072
Supportive Services for Veteran Families (SSVF) Program—Application for Supportive Services Grant
125 fields, 10 pages
10-10072B
Supportive Services for Veteran Families (SSVF) Program—Quarterly Grantee Performance Report
54 fields, 3 pages
10-10072C
Supportive Services for Veteran Families (SSVF) Program—Renewal Application for Supportive Services Grant
53 fields, 14 pages
Who uses VA Form 10-10072A?
The survey text describes who answers it and how VA uses it.
Official sources and the blank
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Questions about Form 10-10072A
Who fills out VA Form 10-10072A?
People who received services from an SSVF supportive services provider. The survey asks them to name and rate that provider.
Is the survey required?
The form says response to this survey is voluntary and failure to participate will have no adverse effect on benefits to which you might otherwise be entitled.
Does the survey include my name?
No. The form says all answers are confidential as survey data does not include names. It asks for the provider's name, not yours.
Which questions do I answer at the end?
The form says questions 7 to 10B are for people who recently began receiving services, and questions 11 to 13B for people no longer receiving services or who will not be in the immediate future.
How long does it take?
The notice estimates an average of 15 minutes per response.