VA Form 10-1465-2 SHEP InPatient Short Form 10-1465-2

OMB Number 2900-0712
Est. Burden: 16 minutes
Exp. Date: 03/31/2017
VA Form 10-1465-2

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
RECENTLY DISCHARGED INPATIENT 2016
In order for the VA to carry out its mission to provide the best possible medical care and
services to all veterans, it is extremely important that you complete and return this survey
booklet. Your answers will help ensure that all veterans receive the high-quality care they have
earned and so richly deserve.
Please read each question and check the box that best describes your experience. Please be
sure to read all pages of this survey booklet.
The check-box responses you provide to the survey questions will not be connected with you
personally but combined with the opinions of other veterans and shared with the VA facility
providing your care. However, any additional information which you provide including
comments written in the margins, letters, and other enclosures will be shared with the Medical
Center Director or appropriate staff at your facility if it is the best way to address your concerns,
unless you instruct us not to.
Participation is voluntary and your answers to the survey will not affect the healthcare you
receive or your eligibility for VA benefits.
If you have a specific question or need help with your VA care, you may contact the VA as
described at the end of this survey booklet.
Thank you very much!
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 16 minutes.
This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
Customer satisfaction surveys are used to gauge customer perceptions of VA services as well as
customer expectations and desires. The results of this survey will lead to improvements in the quality of
service delivery by helping to shape the direction and focus of specific programs and services.
Disclosure of information involves release of statistical data and other non-identifying data for the
improvement of services within the VA healthcare system and associated administrative purposes.
Submission of this form is voluntary and failure to respond will have no impact on benefits to which you
may be entitled.

*** ABOUT YOUR RECENT HOSPITAL STAY ***
We realize that you may receive care at more than one VA location. However, it is important that
you answer the questions in this survey based on your VA hospital stay described below:
Version: 62E – 0416

SURVEY INSTRUCTIONS
•

You should only fill out this survey if you were the patient during the hospital stay named in
the cover letter. Do not fill out this survey if you were not the patient.

•

Answer all the questions by checking the box to the left of your answer.

•

You are sometimes told to skip over some questions in this survey. When this happens you
will see an arrow with a note that tells you what question to answer next, like this:

Yes
 No  If No, Go to Question 1
You may notice a number on the cover letter of this survey. This number is used to let
us know if you returned your survey so we don't have to send you reminders.
Please note: Questions 1-25 in this survey are part of a national initiative to measure the
quality of care in hospitals. OMB #2900-0712
Please answer the questions in this
survey about your stay at the hospital
named on the cover letter. Do not
include any other hospital stays in your
answers.

3.

YOUR CARE FROM NURSES
1.

During this hospital stay, how often
did nurses treat you with courtesy
and respect?

2.

4.

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always
I never pressed the call button

YOUR CARE FROM DOCTORS
5.

During this hospital stay, how often
did doctors treat you with courtesy
and respect?

2

Never
Sometimes
Usually
Always

During this hospital stay, after you
pressed the call button, how often
did you get help as soon as you
wanted it?

During this hospital stay, how often
did nurses listen carefully to you?

During this hospital stay, how often
did nurses explain things in a way
you could understand?

Never
Sometimes
Usually
Always

6.

During this hospital stay, how often
did doctors listen carefully to you?

7.

Never
Sometimes
Usually
Always

During this hospital stay, how often
did doctors explain things in a way
you could understand?

Never
Sometimes
Usually
Always

THE HOSPITAL ENVIRONMENT
8.

During this hospital stay, how often
were your room and bathroom kept
clean?

9.

Never
Sometimes
Usually
Always

During this hospital stay, how often
was the area around your room quiet
at night?

Never
Sometimes
Usually
Always

YOUR EXPERIENCES IN THIS HOSPITAL
10. During this hospital stay, did you

need help from nurses or other
hospital staff in getting to the
bathroom or in using a bedpan?

Yes

No  If No, Go to Question 12

11. How often did you get help in getting

to the bathroom or in using a bedpan
as soon as you wanted?

Never
Sometimes
Usually
Always

12. During this hospital stay, did you

need medicine for pain?

Yes

No  If No, Go to Question 15
13. During this hospital stay, how often

was your pain well controlled?

Never
Sometimes
Usually
Always

14. During this hospital stay, how often

did the hospital staff do everything
they could to help you with your
pain?

Never
Sometimes
Usually
Always

15. During this hospital stay, were you

given any medicine that you had not
taken before?

Yes

No  If No, Go to Question 18
16. Before giving you any new medicine,

how often did hospital staff tell you
what the medicine was for?

Never
Sometimes
Usually
Always

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17. Before giving you any new medicine,

how often did hospital staff describe
possible side effects in a way you
could understand?

Never
Sometimes
Usually
Always

WHEN YOU LEFT THE HOSPITAL
18. After you left the hospital, did you go

directly to your own home, to
someone else’s home, or to another
health facility?

Own home

Someone else’s home

Another health facility  If
Another, Go to Question 21
19. During this hospital stay, did

doctors, nurses or other hospital
staff talk with you about whether you
would have the help you needed
when you left the hospital?

Yes

No
20. During this hospital stay, did you get

information in writing about what
symptoms or health problems to
look out for after you left the
hospital?

Yes

No

OVERALL RATING OF HOSPITAL
Please answer the following questions
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.
21. Using any number from 0 to 10,

where 0 is the worst hospital
possible and 10 is the best hospital
possible, what number would you
use to rate this hospital during your
stay?

0 Worst hospital possible
1
2
3
4
5
6
7
8
9
10 Best hospital possible

22. Would you recommend this hospital

to your friends and family?

Definitely no
Probably no
Probably yes
Definitely yes

UNDERSTANDING YOUR CARE WHEN
YOU LEFT THE HOSPITAL
23. During this hospital stay, staff took

my preferences and those of my
family or caregiver into account in
deciding what my health care needs
would be when I left.

4

Strongly disagree
Disagree
Agree
Strongly agree

24. When I left the hospital, I had a good

28. During this hospital stay, how often

understanding of the things I was
responsible for in managing my
health.

did you feel nurses really cared
about you as a person?

Strongly disagree
Disagree
Agree
Strongly agree

understood the purpose for taking
each of my medications.
Strongly disagree
Disagree
Agree
Strongly agree
I was not given any medication
when I left the hospital

Now we would like to gather some
additional detail on topics we have asked
you about before. These items use a
somewhat different way of asking for your
response since they are getting at a little
different way of thinking about the topics.
FURTHER QUESTIONS ABOUT
YOUR EXPERIENCE
26. During this hospital stay, how often

was personal information about you
treated in a confidential manner?

Never
Sometimes
Usually
Always

27. During this hospital stay, how often

did nurses show respect for what
you had to say?

Never
Sometimes
Usually
Always

29. During this hospital stay, how often

25. When I left the hospital, I clearly

Never
Sometimes
Usually
Always

did doctors show respect for what
you had to say?

Never
Sometimes
Usually
Always

30. During this hospital stay, how often

did you feel doctors really cared
about you as a person?

Never
Sometimes
Usually
Always

31. During this hospital stay, were

providers willing to talk to your
family or friends about your health
or treatment?

Yes

No
32. During this hospital stay, how often

did you have a hard time speaking
with or understanding your doctors
or other health providers because
you spoke different languages?

Never
Sometimes
Usually
Always

5

33. If you could have free care outside

ABOUT COMMUNICATING WITH VA

the VA, would you choose to be
hospitalized here again?

39. Did you have a complaint about how

Definitely would not
Probably would not
Probably would
Definitely would

34. During this hospital stay, how often

did health care providers seem
informed and up-to-date about the
care you got from other providers at
the hospital?

Never
Sometimes
Usually
Always

35. Were there times when you were

confused because different
providers told you different things?

Yes, always

Yes, sometimes

No
36. Did you know who to ask when you had

questions about your health care?

Yes, always

Yes, sometimes

No
37. During this hospital stay, when there

was more than one choice for your
treatment or health care, did providers
ask which choice you thought was best
for you?

Yes

No
38. During this hospital stay, did providers

talk with you about the pros and cons
of each choice for your treatment or
health care?

Yes

No

6

you were treated (medically or
personally) during your last
hospitalization?

Yes

No  If No, Go to Question 49
40. If you reported this complaint to

someone at the VA location where you
received your care, to whom did you
report this complaint?

Treatment team  Go to
Question 42

Patient advocate  Go to
Question 42

Other VA staff  Go to
Question 42

Did not report the complaint to a VA
employee
41. If you did not report this complaint,

what was the most important reason
you did not report it? (Please mark only
one.)

I didn't know where to complain

I was afraid of what would happen if
I did complain

I thought complaining wouldn't do
any good

I wasn't sure I had the right to
complain

Other
42. If you had a complaint, how easy was it

for you to find someone to hear your
complaint?

Very easy

Easy

Difficult

Very difficult

Not applicable

43. If you spoke with someone at the VA

location about a complaint, how
satisfied were you with the way your
complaint was handled?

Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
Not applicable

44. How long did it take for the VA hospital

to resolve your complaint?

Same day

2-7 days

8-14 days

15-21 days

More than 21 days

Complaint is not resolved

Not applicable
YOUR OVERALL EXPERIENCE WITH THE
DEPARTMENT OF VETERANS AFFAIRS
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:
45. I got the service I needed.

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

46. It was easy to get the service I needed.

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

47. I felt like a valued customer.

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

48. I trust VA to fulfill our country’s

commitment to veterans.

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree
ABOUT YOU
There are only a few remaining items
left.
49. During this hospital stay, were you

admitted to this hospital through the
Emergency Room?

Yes

No
50. In general, how would you rate your
overall health?

Excellent
Very good
Good
Fair
Poor

51. In general, how would you rate your

overall mental or emotional health?

Excellent
Very good
Good
Fair
Poor

7

52. What is the highest grade or level of

school that you have completed?

8th grade or less

Some high school, but did not
graduate

High school graduate or GED

Some college or 2-year degree

4-year college graduate

More than 4-year college degree
53. Are you of Spanish, Hispanic or Latino

origin or descent?

No, not Spanish/Hispanic/Latino

Yes, Puerto Rican

Yes, Mexican, Mexican American,
Chicano

Yes, Cuban

Yes, other Spanish/Hispanic/Latino

54. What is your race? Please choose one

or more.

White

Black or African American

Asian

Native Hawaiian or other Pacific
Islander

American Indian or Alaska Native
55. What language do you mainly speak at

home?

English

Spanish

Chinese

Russian

Vietnamese

Portuguese

Some other language (please print):
_______________________________

If you have a specific question or need help with your VA care, you may contact the VA:
1. By telephone:
a. VA Benefits: 1-800-827-1000
b. Health Care Benefits: 1-877-222-8387
c. Telecommunications Device for the Deaf (TDD): 1-800-829-4833
2. Information on a broad range of veterans' benefits is available on our home page at
http:// www.va.gov
3. At your local VA medical center, either contact the department that you think can help
you or ask for the Patient Advocate.
If you have a specific question about this HCAHPS survey, call 1-866-594-5444.
If you have a specific question about something other than this HCAHPS survey, please refer
to the contact options above.
Your answers are important to help us improve VA care. Thank you for completing this
questionnaire. Please place the completed questionnaire in the envelope we sent you. No
stamp is required. Simply place the envelope in any mailbox and return the survey to:
Department of Veterans Affairs
c/o Ipsos
P.O. Box 806046
Chicago, IL 60680
Questions 1-22 and 49-55 are part of the Hospital CAHPS survey and are works of the U.S.
Government. These questions are in the public domain and therefore are NOT subject to U.S.
copyright laws. The three Care Transitions Measure® questions (Questions 23-25) are
copyright of The Care Transitions Program® (www.caretransitions.org).

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