VA Form 10-1465-10 SHEP VA Community Care

OMB Number 2900-0712
Est. Burden: 11 minutes
VA Form 10-1465-10

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS: SHEP
VA COMMUNITY 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 and shared with those responsible for
managing VA Community Care. However, any additional information which you provide including
comments written in the margins, letters, and other enclosures will be shared with the appropriate staff
at your VA 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 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 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: 24 – 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 VA
COMMUNITY CARE

YOUR ELIGIBILITY FOR
VA COMMUNITY CARE

This survey is about VA Community Care (for
example, the Veterans Choice Program). VA
Community Care refers to all care provided to
eligible Veterans outside of the VA medical
system but paid for completely or in part by
VA.

A Veteran must meet eligibility requirements
in order to receive VA Community Care. The
next questions are about your experience
with determining your eligibility for VA
Community Care.
Please tell us how you feel about the
following statements:

In the remainder of this survey, we will use
“VA Community Care” or “this service” to
refer to the VA Community Care healthcare
service listed in Question 1 below.
1.

3.







Our records show that within the past 3
months you have received VA
Community Care for the following type
of healthcare service:

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Is that right?



2.

4.

Yes
No If No, go to #41

Within the last 3 months
4-6 months ago
7-12 months ago

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

The information available about
eligibility for VA Community Care is
helpful.







When did you first begin to receive this
service?







The eligibility requirements for VA
Community Care are clear.

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

Over a year ago
I am not sure

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9.

YOUR REFERRAL AND GETTING YOUR FIRST
APPOINTMENT FOR VA COMMUNITY CARE







Please tell us how you feel about the
following statements:
5.

The process for scheduling my first
appointment for this service was clearly
explained to me.






6.

7.

Disagree







Neither agree nor disagree
Agree
Strongly agree

Disagree
Neither agree nor disagree
Agree
Strongly agree

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

11. I understand the process for getting VA
Community Care, including determining
eligibility, finding a community provider,
and scheduling an appointment.

Strongly disagree
Disagree
Neither agree nor disagree







Agree
Strongly agree

Strongly disagree

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
YOUR RECENT APPOINTMENTS
FOR VA COMMUNITY CARE

Disagree

Next please tell us about your experience
getting appointments for the service named
in Question 1 during the last 3 months.

Neither agree nor disagree
Agree
Strongly agree

12. In the last 3 months, how many times
have you received this service?

I had enough say in selecting the date
and time of my first appointment for this
service.







Strongly disagree

10. It was easy to get my first appointment
for this service.

I had enough say in selecting a VA
Community Care provider for this
service.






8.

Strongly disagree

It was clear who was responsible for the
process of arranging my first
appointment for this service.







I was able to get my first appointment
for this service as soon as I needed.









Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

None  If None, go to #41
1 time
2
3
4
5 to 9
10 or more times

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13. In the last 3 months, how often did you
get an appointment for this service as
soon as you needed?






17. In the last 3 months, how often did your
VA Community Care provider explain
things in a way that was easy to
understand?

Never






Sometimes
Usually
Always

14. In the last 3 months, how often were
you able to get an appointment for this
service at a convenient date and time?






Never






Sometimes
Usually
Always

Usually
Always

Never
Sometimes
Usually
Always

19. In the last 3 months, did you talk with
your VA Community Care provider
about any health questions or
concerns?

Never
Sometimes




Usually
Always

Yes
No  If No, go to #21

20. In the last 3 months, how often did your
VA Community Care provider give you
easy to understand information about
these health questions or concerns?

YOUR EXPERIENCE WITH
VA COMMUNITY CARE






The next questions are about your
experience with the provider of your VA
Community Care, and about the
coordination of your care with your VA
providers in the last 3 months.
16. Wait time includes time spent in a
waiting room and exam room. In the
last 3 months, how often did you see
your VA Community Care provider
within 15 minutes of your scheduled
appointment time?






Sometimes

18. In the last 3 months, how often did your
VA Community Care provider listen
carefully to you?

15. In the last 3 months, how often were
you able to receive this service at a
convenient location?






Never

Never
Sometimes
Usually
Always

21. In the last 3 months, how often did your
VA Community Care provider seem to
know the important information about
your medical history?






Never
Sometimes
Usually

Never
Sometimes
Usually
Always

Always

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22. In the last 3 months, how often did your
VA Community Care provider seem
informed and up-to-date about any care
you received from VA providers?








26. In the last 3 months, how often did your
VA Community Care provider spend
enough time with you?






Never
Sometimes
Usually
Always
Does not apply If Does not apply,
go to #24




Never
Sometimes






Usually
Always
I do not know

Always

Yes
No  If No, go to #30

Never
Sometimes
Usually
Always

29. In the last 3 months, when your VA
Community Care provider ordered a blood
test, x-ray or other test for you, how often
were the results also sent to the VA?

Never
Sometimes







Usually
Always

25. In the last 3 months, how often did your
VA Community Care provider show
respect for what you had to say?






Usually

28. In the last 3 months, when your VA
Community Care provider ordered a
blood test, x-ray or other test for you,
how often did someone from your VA
Community Care provider’s office follow
up to give you those results?

24. In the last 3 months, how often was it
clear what the next step in your care
would be?






Sometimes

27. In the last 3 months, did your VA
Community Care provider order a blood
test, x-ray, or other test for you?

I do not know

23. In the last 3 months, how often did your
VA provider(s) seem informed and upto-date about your VA Community
Care?







Never

Never
Sometimes
Usually
Always
I do not know

30. In the last 3 months, when you contacted
your VA Community Care provider’s
office during regular office hours, how
often did you get an answer to your
medical question that same day?

Never
Sometimes
Usually
Always







Never
Sometimes
Usually
Always
Does not apply

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35. 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 your VA
Community Care provider?

31. In the last 3 months, when you contacted
your VA Community Care provider’s office
after regular office hours, how often did
you get an answer to your medical
question as soon as you needed?



















Never
Sometimes
Usually
Always
Does not apply

32. In the last 3 months, did you contact your
VA Community Care provider’s office
using email, a web site or online tool?





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

33. In the last 3 months, when you contacted
your VA Community Care provider’s
office using email, a web site or online
tool, how often did you get a helpful
response as soon as you needed?






1
2
3
4
5
6
7
8
9
10 Best provider possible

BILLING FOR VA COMMUNITY CARE
The next questions ask about any bills and
out-of-pocket expenses related to your VA
Community Care.

Never
Sometimes

36. In the last 3 months, how often was it
clear whether or not you would have to
make any out-of-pocket payments for
your VA Community Care?

Usually
Always






34. In the last 3 months, when you phoned
your VA Community Care provider’s
office, how often did you get a helpful
response as soon as you needed?







0 Worst provider possible

Never
Sometimes

Never
Sometimes
Usually
Always

37. In the last 3 months, how often was the
information about billing for VA
Community Care clear?

Usually
Always






Does not apply

Never
Sometimes
Usually
Always

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38. In the last 3 months, have you received
any bills for your VA Community Care?




ABOUT YOU

Yes

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

No  If No, go to #40







39. In the last 3 months, how often has the
process for handling bills for VA
Community Care gone smoothly?






Never
Sometimes
Usually

Very Good
Good
Fair
Poor

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

Always







YOUR OVERALL EXPERIENCE WITH
VA COMMUNITY CARE
40. Overall, how satisfied are you with your
VA Community Care during the last 3
months?








Excellent

Very dissatisfied

Excellent
Very Good
Good
Fair
Poor

43. Under which of the following types of
health insurance or health plans are you
currently covered? Check all that apply.

Dissatisfied
Somewhat dissatisfied
Somewhat satisfied
Satisfied
Very satisfied





Medicare




Employer or private insurance plan

Medicaid
Tricare, Indian Health Service, or
other government healthcare plan
(not including VA)
None, not insured

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47. What is your gender?

44. 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








Yes, Hispanic or Latino
No, Not Hispanic or Latino

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







Woman
Transgender Man
Transgender Woman
Non-binary
Other

48. Do you consider yourself to be:

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




Man

White
Black or African-American

Heterosexual or straight
Gay
Lesbian
Bisexual
Other
I am not sure

Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native

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 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

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