VA Form 10-10065: Ethics Consultation Feedback Tool – VA Form 10-10065, officially titled the Ethics Consultation Feedback Tool (ECFT), is a voluntary survey used by the U.S. Department of Veterans Affairs (VA) to gather feedback from patients, family members, and staff who have participated in an ethics consultation.
Revised in May 2016, this one-page form helps the VA’s National Center for Ethics in Health Care improve its Ethics Consultation Service. It collects anonymous or identifiable input on the quality of support provided during ethical dilemmas in healthcare.
Understanding Ethics Consultations in VA Healthcare
VA ethics consultations assist patients, families, and healthcare staff in navigating complex ethical issues, such as treatment decisions, end-of-life care, confidentiality, or conflicts between values. The service, part of the VA’s Integrated Ethics Program, aims to listen to all perspectives and help identify the best course of action.
The National Center for Ethics in Health Care serves as the VA’s central resource for these services, supporting facilities nationwide through education, policy guidance, and consultation standards.
Purpose of the Ethics Consultation Feedback Tool
The primary goal of VA Form 10-10065 is continuous quality improvement. Feedback from users helps shape ethics services, ensuring they remain patient-centered, respectful, and effective.
Key objectives include:
- Measuring satisfaction with consultant performance.
- Identifying strengths and areas for improvement in the consultation process.
- Gathering suggestions to enhance service delivery.
- Supporting the VA’s commitment to ethical healthcare practices.
Completion is voluntary and takes about 5 minutes. Responses do not affect benefits or care.
How to Complete VA Form 10-10065?
The form uses a simple rating scale for various aspects of the consultation experience:
- Excellent, Very Good, Good, Fair, Poor, or N/A (Not Applicable)
Rated items typically include:
- Making you feel at ease
- Respecting your opinions
- Expertise in ethics
- Providing useful information and clear explanations
- Clarifying decision-making roles and options
- Resolving disagreements
- Accessibility and timeliness
- Overall helpfulness of the service
Additional questions ask whether recommendations were made and followed, plus an open space for comments or suggestions.
Download the official form here: VA Form 10-10065 (PDF)
Who Should Use the Ethics Consultation Feedback Tool?
- Veterans and their families who participated in an ethics consultation.
- VA healthcare staff involved in the process.
- Anyone seeking to provide constructive input on VA ethics services.
Feedback directly contributes to better support for future ethical challenges in VA facilities.
Benefits of Providing Feedback via VA Form 10-10065
Your input helps:
- Enhance the quality and consistency of ethics consultations across VA.
- Train and support ethics consultants more effectively.
- Strengthen trust in VA’s commitment to ethical, compassionate care.
- Inform broader improvements in the Integrated Ethics Program.
How to Access VA Ethics Support?
If you need an ethics consultation or have questions:
- Contact your local VA medical facility’s Ethics Consultation Service.
- Visit the National Center for Ethics in Health Care website.
- Speak with your care team about initiating a consult.
For more on VA forms and healthcare resources, explore official VA pages.
Download VA Form 10-10065
Direct PDF Download: https://www.va.gov/vaforms/medical/pdf/vha-10-10065.pdf
This form is available through the official VA Forms Library and remains a key tool for improving ethics services for America’s veterans.
This article is for informational purposes only and is based on publicly available VA resources. Always refer to official VA channels for the most current guidance.