Shared Decision Making

Veteran SDM Questionnaire

OMB No. 2900-0770
Estimated Burden:10 minutes

Expiration Date: 08/31/2017

The 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 survey will average 10 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone survey will lead to improvements in the quality of service delivery by helping to achieve services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VA Form 10-
APR 2014

Short Veteran SDM Qs

1. Have you viewed the online Guide/GEC Website?  Yes  No

2. Have you reviewed the folder with the written Summary of Services and Supports and other handouts?

 Yes  No

3. Have you used the Shared Decision Making Worksheet for Veterans?  Yes  No

4. Who is the main person you have talked with at the VA about your options and choices related to long term services and supports?

Is this person a:  Social worker?  Care coordinator?  Nurse?  Doctor?

5. Did this person talk with you about your preferences and what is most important to you related to long term services and supports?  Yes  No

6. Did your provider, this person, or other VA staff talk with you about how your illnesses or conditions may affect what you can do and what kind of help you might need from long term services and supports?  Yes  No

7. Do you have a family member/friend who helps you make health-related decisions?

 Yes  No

8. If Yes, has that person used the Self-Assessment Worksheet for Caregivers?

 Yes  No  NA (answered no to #7)

9. On a scale of 0 to 10 where 0 is not helpful at all and 10 is extremely helpful, how would you rate your discussions related to LTSS with VA providers and other staff?

0. 1 2 3 4 5 6 7 8 9 10

1. = not at all helpful 10 = extremely helpful

10. On a scale of 0 to 10, where 0 is not at all and 10 is very confident, after discussions with staff about LTSS, how confident are you that there is an understanding among VA staff, yourself and your caregiver regarding capabilities, goals and priorities?

0 1 2 3 4 5 6 7 8 9 10

0 = Not at all confident 10 = Very confident

11. On a scale of 0 to 10, where 0 is not at all and 10 is very confident, how confident are you that you know what to do if you need more information about long term services and supports?

0 1 2 3 4 5 6 7 8 9 10

0 = Not at all confident 10 = Very confident

12. On a scale of 0 to 10, where 0 is not at all and 10 is very confident, how confident are you that you can make a good decision about long term care, either now or in the future?

0 1 2 3 4 5 6 7 8 9 10

0 = Not at all confident 10 = Very confident

13. On a scale of 0 to 10, where 0 is not at all likely and 10 is very likely, how likely are you to recommend the Shared Decision Making to other Veterans and their families?

0 1 2 3 4 5 6 7 8 9 10

0 = Not at all likely 10 = Very likely

14. Is where you live: rural, suburban, or urban? _________________________________

How far is the VA location you go to the most often from your home (in travel time or miles)?

Travel time: ________________ Miles: _____________________

15. Now think about your experiences with all the services provided by the Department of Veterans Affairs (which include healthcare, benefits programs, or memorial services). Please tell us how you feel about the following statements:

“I got the service I needed.”

A. Strongly Disagree

B. Disagree

C. Neither Agree nor Disagree

D. Agree

E. Strongly Agree

“It was easy to get the service I needed.”

A. Strongly Disagree

B. Disagree

C. Neither Agree nor Disagree

D. Agree

E. Strongly Agree

“I felt like a valued customer.”

A. Strongly Disagree

B. Disagree

C. Neither Agree nor Disagree

D. Agree

E. Strongly Agree

“I trust VA to fulfill our country’s commitment to veterans.”

A. Strongly Disagree

B. Disagree

C. Neither Agree nor Disagree

D. Agree

E. Strongly Agree

16. Is there anything else you would like to tell us about your experience making LTSS choices at VA?

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