VA Form 10-1463-9 SHEP_SC Survey_10-1465-9

OMB Number 2900-0712
Est. Burden: 11 minutes
Exp. Date: 03/31/2017
VA Form 10-1465-9

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
SPECIALTY CARE 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 11 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.

Version: 14 - 0416

SURVEY INSTRUCTIONS
•

Answer each question by marking 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 If Yes, go to #1
No
YOUR CARE FROM THIS PROVIDER
IN THE LAST 6 MONTHS

VA SPECIALTY CARE CLINIC
1.

Our records show that you got care
at the VA specialty care clinic named
below in the last 6 months.

These questions ask about your own
health care. Do not include care you got
when you stayed overnight in a hospital.
Do not include the times you went for
dental care visits.

[SC_Clinic]
Facility: [OFFICIAL]

Is that right?




4.

Yes
NoIf No, go to #0









For the questions in this survey booklet,
“this provider” refers to the type of
specialist you saw at the clinic
mentioned above.
2.

Is this the provider you usually see if
you need a check-up, want advice
about a health problem, or get sick
or hurt?



3.

In the last 6 months, how many times
did you visit this provider to get care
for yourself?

1 time
2
3
4
5 to 9
10 or more times

How long have you been going to
this provider?

In the last 6 months, did you contact
this provider’s office to get an
appointment for an illness, injury or
condition that needed care right
away?











5.

None If None, go to #0

Yes
No

Less than 6 months
At least 6 months but less than
1 year
At least 1 year but less than
3 years
At least 3 years but less than
5 years
5 years or more
2

Yes
No If No, go to #7

6.

In the last 6 months, when you
contacted this provider’s office to
get an appointment for care you
needed right away, how often did
you get an appointment as soon as
you needed?





7.

Never

Yes
No If No, go to #11

10. In the last 6 months, when you
contacted this provider’s office
during regular office hours, how
often did you get an answer to your
medical question that same day?

Sometimes
Usually
Always






Yes
No If No, go to #9

In the last 6 months, when you made
an appointment for a check-up or
routine care with this provider, how
often did you get an appointment as
soon as you needed?






In the last 6 months, did you contact
this provider’s office with a medical
question during regular office
hours?




In the last 6 months, did you make
any appointments for a check-up or
routine care with this provider?



8.

9.

Never
Sometimes
Usually
Always

11. Wait time includes time spent in the
waiting room and exam room. In the
last 6 months, how often did you see
this provider within 15 minutes of
your appointment time?






Never
Sometimes
Usually
Always

3

Never
Sometimes
Usually
Always

16. In the last 6 months, how often did
this provider seem to know the
important information about your
medical history?

12. In the last 6 months, how often did
this provider explain things in a way
that was easy to understand?






Never






Sometimes
Usually
Always

13. In the last 6 months, how often did
this provider listen carefully to you?






Never
Sometimes






Usually
Always

Usually
Always

Never
Sometimes
Usually
Always

18. In the last 6 months, how often did
this provider spend enough time
with you?

Yes
No If No, go to #16






15. In the last 6 months, how often did
this provider give you easy to
understand information about these
health questions or concerns?






Sometimes

17. In the last 6 months, how often did
this provider show respect for what
you had to say?

14. In the last 6 months, did you talk
with this provider about any health
questions or concerns?




Never

Never
Sometimes
Usually
Always

4

Never
Sometimes
Usually
Always

19. In the last 6 months, did this
provider order a blood test, x-ray, or
other test for you?




22. In the last 6 months, did you take
any prescription medicine?




Yes
No If No, go to #21






Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

CLERKS AND RECEPTIONISTS

21. Using any number from 0 to 10,
where 0 is the worst provider
possible and 10 is the best provider
possible, what number would you
use to rate this provider?













No If No, go to #24

23. In the last 6 months, how often did
you and someone from this
provider’s office talk about all the
prescription medicines you were
taking?

20. In the last 6 months, when this
provider ordered a blood test, x-ray,
or other test for you, how often did
someone from this provider’s office
follow up to give you those results?






Yes

24. In the last 6 months, how often were
clerks and receptionists at this
provider’s office as helpful as you
thought they should be?

0 Worst provider possible






1
2
3
4

Never
Sometimes
Usually
Always

25. In the last 6 months, how often did
clerks and receptionists at this
provider’s office treat you with
courtesy and respect?

5
6
7






8
9
10 Best provider possible

5

Never
Sometimes
Usually
Always

YOUR OVERALL EXPERIENCE WITH THE
DEPARTMENT OF VETERANS AFFAIRS

ABOUT YOU
30. In general, how would you rate your
overall health?

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:







26. I got the service I needed.







Strongly disagree
Neither agree nor disagree







Agree
Strongly agree

Strongly disagree
Neither agree nor disagree
Agree
Strongly agree

Strongly disagree
Disagree
Neither agree nor disagree

Fair
Poor

Excellent
Very Good
Good
Fair
Poor




8th grade or less






High school graduate or GED

Some high school, but did not
graduate
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

33. Are you of Hispanic or Latino origin
or descent?

Agree
Strongly agree




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







Good

32. What is the highest grade or level of
school that you have completed?

Disagree

28. I felt like a valued customer.







Very Good

31. In general, how would you rate your
overall mental or emotional health?

Disagree

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







Excellent

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

6

Yes, Hispanic or Latino
No, Not Hispanic or Latino

36. Did someone help you complete this
survey?

34. What is your race? Mark one or
more.











White
Black or African-American
Asian
Native Hawaiian or other
Pacific Islander
American Indian or Alaska Native

No  Thank you. Please return
the completed survey in
the postage-paid
envelope.

37. How did that person help you? Mark
one or more.

Other






35. What language do you mainly speak
at home?









Yes

English
Spanish
Chinese



Russian

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way

Vietnamese
Portuguese
Some other language (please print):

________________________

THANK YOU
Please return the completed survey in the postage-paid envelope.
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.
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
7

This section was intentionally left blank.
Please do not write in this area.