VA Form 10-1465-9 SHEP Specialty Care Survey

OMB Number 2900-0712
Est. Burden: 12 minutes
VA Form 10-1465-9

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS: SHEP
SPECIALTY CARE 2021
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 before being reported. However, any
additional information which you provide including comments written in the margins, letters, and other
enclosures will be shared with my office unless you indicate that you want your comments to remain
confidential and not be shared. If you would like to see the results of the survey for all Veterans who
get care at this facility, you may contact the Patient Advocate at this facility.
Participation is voluntary and your answers to the survey will not affect the health care 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 12 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 - 0421

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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.
4.

<>
Facility: <>









Is that right?




Yes
NoIf No, go to #37

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.

5.

Yes





6.

Less than 6 months
At least 6 months but less than
1 year
At least 1 year but less than
3 years

5 years or more

2

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

Yes
No If No, go to #7

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?






At least 3 years but less than
5 years

None If None, go to #37

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?




No

How long have you been going to this
provider?




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

Never
Sometimes
Usually
Always

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7.



8.






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?





9.

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

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






Never
Sometimes
Usually
Always




Yes
No If No, go to #11

Always

Never
Sometimes
Usually
Always

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?






Never
Sometimes
Usually
Always

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?

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?






Usually

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

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

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

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




Never






Never
Sometimes
Usually

Never
Sometimes
Usually
Always

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

Always






3

Never
Sometimes
Usually
Always

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

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









Never
Sometimes
Usually
Always






Yes
No If No, go to #21

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?






Never
Sometimes
Usually
Always

CLERKS AND RECEPTIONISTS
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?

Never
Sometimes






Usually
Always

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?

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




Yes

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?

0 Worst provider possible
1






2
3
4
5

Never
Sometimes
Usually
Always

6
7
8
9
10 Best provider possible

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USING THE VA PHARMACY
26. During the past 3 months, when you were
seen at <>, did you visit
the pharmacy outpatient window to get your
prescription(s) filled?





Yes
No If No, go to #29
No pharmacy outpatient window at this
facility If No outpatient window,
go to #29

27. For each part of your VA pharmacy visit, please tell us the amount of improvement needed, if any:
No
Improvement
Needed

Slight
Improvement
Needed

Some
Improvement
Needed

A lot of
Improvement
Needed

Does
Not Apply

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a. The length of time you waited
at the VA pharmacy
b. Questions were answered to
your satisfaction by pharmacy
staff
c. The courtesy of the VA
pharmacy staff
d. Personal privacy in the VA
pharmacy waiting room
e. VA pharmacy waiting room
comfort & cleanliness
f. Contacting the VA pharmacy
by phone when you have
questions about your
medication
g. Contacting your VA
healthcare provider when you
have questions about your
medication

28. Overall, how satisfied were you with
pharmacy services provided at the
<> pharmacy outpatient
window during the past three months?







29. During the past 3 months, did you receive
medications or supplies from the VA
pharmacy in the mail?




Very satisfied

Yes
No If No, go to #32

Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

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30. Please tell us about the medications or supplies you received from the VA pharmacy in the mail.
How often did these things happen to you?
a. I received the wrong medication or supplies
b. The medication or supplies were for another
person
c. The amount of medication or supplies received
was too small
d. The amount of medication or supplies received
was too large
e. The package had no medication or supplies
f.

The package was damaged

g. The medication in the package was too hot
h. The medication in the package was too cold
i. There was an unexplained change to the
medication or supplies I received

31. Overall, how satisfied were you with VA
pharmacy services provided through
the mail during the past 3 months?







Sometimes

Usually

Always

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33. In the last 6 months, when you contacted
this provider’s office using secure
messaging, how often did you get a
helpful response as soon as you needed?

Very satisfied
Satisfied






Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

Never
Sometimes
Usually
Always

34. In the last 6 months, did you phone this
provider’s office?

CONTACTING THIS PROVIDER’S OFFICE
BY SECURE MESSAGING OR TELEPHONE




Next, we would like to learn more about the
contacts that you may have had with this
provider’s office other than face-to-face
appointments.

Yes
No If No, go to #36

35. In the last 6 months, when you phoned
this provider’s office, how often did you
get a helpful response as soon as you
needed?

32. In the last 6 months, did you use secure
messaging online to contact this
provider’s office?





Never






Yes
No If No, go to #34
I am not sure If not sure, go to #34

6

Never
Sometimes
Usually
Always

IPS_SHEP_CG_SC_SVY_ENG_01.21

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

YOUR OVERALL EXPERIENCE WITH VA
HEALTH CARE
36. Overall, how satisfied are you with the
health care you have received at your
VA facility during the last 6 months?

 Very Dissatisfied
 Dissatisfied
 Somewhat Dissatisfied
 Somewhat Satisfied
 Satisfied
 Very Satisfied






High school graduate or GED




37. In general, how would you rate your
overall health?

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

Yes, Hispanic or Latino
No, Not Hispanic or Latino

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






Excellent
Very Good
Good
Fair
Poor



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







8th grade or less

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

ABOUT YOU










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

42. What language do you mainly speak at
home?

Excellent









Very Good
Good
Fair
Poor

English
Spanish
Chinese
Russian
Vietnamese
Portuguese
Some other language (please print):

________________________

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IPS_SHEP_CG_SC_SVY_ENG_01.21

45. Did someone help you complete this
survey?

43. What is your gender?








Man




Woman
Transgender Man

No 

Transgender Woman

Thank you. Please return
the completed survey in the
postage-paid envelope.

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

Non-binary
Other

44. Do you consider yourself to be:








Yes

Heterosexual or straight
Gay
Lesbian
Bisexual






Read the questions to me



Helped in some other way

Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language

Other
I am not sure

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. Healthcare 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 this 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

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IPS_SHEP_CG_SC_SVY_ENG_01.21