VA Form 10-10069 Research Questionnaire

OMB 2900-XXXX
Estimated Burden: 15 min.

Department of Veterans Affairs
Veterans Health Administration

POINT-OF-CARE RESEARCH QUESTIONNAIRE
Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork
Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to a collection
of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who
complete this research questionnaire will average 15 minutes. This includes the time it will take to read information
provided and gather the necessary facts to fill out the form. Submission of this form is voluntary and failure to respond will
have no impact on benefits to which you may be entitled.

QUESTIONNAIRE
The following questions refer to Point-of-Care Research (POC-R). Please circle the number that
best reflects your opinion. There is NO right or wrong answer.
EXAMPLE: I believe that research is important to improving care
Strongly Disagree

1

2

3

4

5

6

7

Strongly Agree

1. I think the POC-R program is a good thing for the VA.
Strongly Disagree
1
2
3
4
5
6

7

Strongly Agree

2. f I was approached to be in a POC-R study for one of my health problems, I would likely
participate.
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
3. If I am randomized by the computer to a treatment, the relationship with your doctor would
change a lot
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
4. If I am randomized by the computer to a treatment, the quality of the care I receive would
decrease:
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
5. If I am randomized by the computer to a treatment, I am worried that my doctor would have less
control over my care:
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
6. I would be willing to participate in a POC-R study if my provider is in agreement with it:
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
7. If I am randomized by the computer to a treatment, I expect I will still receive a full explanation
of my care:
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
8. If I am randomized by the computer to a treatment, I am contributing to better care for all
veterans:
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree

VA Form 10-10069
JUL 2012

1

9. Researchers reviewing my medical chart and extracting data would bother me.
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
10. I think the POC-R program will be valuable for the VA.
Strongly Disagree
1
2
3
4
5
6

7

Strongly Agree

11. I believe that the POC-R program will improve the quality of care at the VA.
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
12. I think the POC-R program will help all of the veterans.
Strongly Disagree
1
2
3
4
5
6

7

Strongly Agree

13. Participating in clinical research would make me feel like a guinea pig.
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
14. Participating in a POC-R study would likely be confusing.
Strongly Disagree
1
2
3
4
5
6

7

Strongly Agree

15. I don’t trust the VA to take care of me if I was enrolled in a POC-R study.
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree
16. I would you be willing to give a blanket (covers all studies) consent yearly to be part of local ongoing POC-R studies.
Strongly Disagree
1
2
3
4
5
6
7
Strongly Agree

These questions are asking about what is important for YOU. For these a number”4” is Neutral
17. Being informed of the results of a research program is:
Not very important 1
2
3
4
5
6

7

Very important

18. Giving consent at the beginning of every study is:
Not very important 1
2
3
4
5

6

7

Very important

19. My relationship with my doctor is very important to me.
Not very important 1
2
3
4
5
6

7

Very important

20. For you, receiving compensation for participating in research is:
Not very important 1
2
3
4
5
6
7

Very important

21. Keeping your personal health record private is:
Not very important 1
2
3
4
5

Very important

6

7

The following questions will be answered YES or NO:
22. I have been consented to participate in a research study before today (please circle).
YES

NO

23 I know other people that have participated in research studies
YES

VA Form 10-10069
JUL 2012

NO

2