VA Form 10-1465-11 SHEP Recent Visit Survey

OMB Number 2900-0712
Est. Burden: 13 minutes
VA Form 10-1465-11

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS: SHEP
YOUR RECENT VISIT
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 13 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.

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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
These questions ask about your most recent
visit with this provider.

YOUR PROVIDER
1.

Visits with a healthcare provider can be in
person, by phone, or by video. Our records
show that you had a recent visit with the
provider named below.

4.

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5.

Is that right?

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No If No, go to #38
6.

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3.

7.

Yes
No

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
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Less than 1 month

8.

At least 1 month but less than 3 months
At least 3 months but less than 6 months

1 year or more
9.

Yes
No If No, go to #8

Yes, definitely
Yes, somewhat
No

Yes, definitely  Go to #10
Yes, somewhat  Go to #10
No  If No, go to #10

Was your most recent visit with this
provider by phone?



2

No If No, go to #9

During your most recent visit, was the
video easy to use?


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At least 6 months but less than 1 year

Yes

Did this provider’s office give you all the
instructions you needed to use video for
this visit?

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How long has it been since your most
recent in-person, phone, or video visit with
this provider?

No

Did you need instructions from this
provider’s office about how to use video for
this visit?




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

Yes If Yes, go to #11

Was your most recent visit with this
provider a video visit?




Yes

Please think of this provider as you answer the
survey.
2.

Was your most recent visit with this
provider in person?

Yes
No If No, go to #11

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10. During your most recent visit, were you and
this provider able to hear each other
clearly?

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

17. During your most recent visit, did this
provider spend enough time with you?





Yes, definitely
Yes, somewhat
No


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

Yes
No If No, go to #13

12. Was that recent visit as soon as you
needed?


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Yes, definitely

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Yes, somewhat
No
Yes, definitely

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Yes, somewhat
No

Yes, definitely

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Yes, somewhat
No

Yes, definitely
Yes, somewhat
No

16. During your most recent visit, did this
provider show respect for what you had to
say?





Yes, somewhat
No

Yes
No If No, go to #21

Yes
No

21. Using any number from 0 to 10, where 0 is
the worst visit possible and 10 is the best
visit possible, what number would you use
to rate your most recent visit?

15. During your most recent visit, did this
provider listen carefully to you?





Yes, definitely

20. Did someone from this provider’s office
follow up to give you those results?

14. During your most recent visit, did this
provider explain things in a way that was
easy to understand?





No

19. During your most recent visit, did this
provider order a blood test, x-ray, or other
test for you?

13. Did your most recent visit start on time?





Yes, somewhat

18. During your most recent visit, did this
provider have the medical information they
needed about you?

11. Was your most recent visit for an illness,
injury, or condition that needed care right
away?




Yes, definitely

Yes, definitely

0

Worst visit possible

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

Yes, somewhat
No

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STAFF AT PROVIDER’S OFFICE

23. Thinking about your most recent visit, was
the staff from this provider’s office as
helpful as you thought they should be?

22. Staff at a provider’s office may talk with
you about your visit, help set it up, and
remind you about your appointment.
Thinking about your most recent visit, did
you talk to staff from this provider’s office?








Yes

Yes, definitely
Yes, somewhat
No

24. Thinking about your most recent visit, did
the staff from this provider’s office treat
you with courtesy and respect?

No If No, go to #25





Yes, definitely
Yes, somewhat
No

25. Which of these if any were a problem during your most recent video or phone visit? If your most
recent visit was in person, please select “Does Not Apply.”

a. Quality of video image
b. Provider skill doing video visits
c. Interrupted or dropped connection
d. Level of privacy and confidentiality
at my location
e. Level of privacy and confidentiality
at the provider’s location
f. Provider was interrupted or
distracted

Big
Problem

Moderate
Problem

Small
Problem

Not a
Problem

Does Not
Apply

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27. Thinking about the reason(s) for your
most recent visit, how would you rate
the quality of the care you received?

26. Thinking about the reason(s) for your
most recent video or phone visit, did
the lack of physical contact with your
provider limit the quality of the care
you received?












Yes, definitely
Yes, somewhat
No
Does not apply – most recent visit
was in person

Poor
Fair
Good

Very Good
Excellent

28. Thinking about the reason(s) for your
most recent visit, would you recommend
the same kind of visit (video, phone or inperson) to other Veterans who had the
same reason(s) for seeking care?




4

Yes, definitely
Yes, somewhat
No
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ABOUT YOUR CARE
DURING THE PAST 6 MONTHS

33. Overall, how satisfied are you with the
health care you have received at your
VA facility during the last 6 months?

29. During the past 6 months, have you
delayed or avoided medical care due
to concerns related to COVID-19?

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

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Yes
No If No, go to #31

30. Please indicate the type(s) of care you
delayed or avoided due to COVID-19
during the past 6 months. Please check
all that apply.









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Emergency Care (such as care for
immediate life-threatening conditions)

Somewhat Dissatisfied
Somewhat Satisfied

Satisfied
Very Satisfied

In this next section, we are interested in
learning about how Veterans use
technology for their health and well-being.
These next questions will focus on your
experiences during the last 12 months.

Urgent Care (such as care for immediate
non-life-threatening conditions)
Routine Care (such as annual checkups)

34. In the last 12 months, have you had any
questions about your VA-prescribed
medications or VA provider’s
recommendations (e.g., about follow-up
appointments or tests, monitoring your
health such as your blood pressure,
diet, exercise, or other
recommendations)?

Care from a specialist provider like a
surgeon, a heart doctor, a skin doctor or
another doctor who specializes in one
area of health care
Blood test, x-ray or other test
Treatment or therapy such as physical
therapy, speech therapy or acupuncture




Care for your mental or emotional health

Yes
No If No, go to #36

35. How did you get answers to these
health questions? Select all that apply.



Postponed an in-person visit to a later
date




Changed an in-person visit to a phone
visit
Changed an in-person visit to a video
visit
Took additional safety precautions when
I came for an in-person visit



None of the above  Go to #33



32. Did those action(s) taken by VA related to
COVID-19 meet your healthcare needs?





Dissatisfied

USING MY HEALTHeVET AND OTHER
HEALTH TECHNOLOGY

31. During the past 6 months, which if any of
the following actions did the VA take
related to COVID-19? Please check all
that apply.



Very Dissatisfied



Yes, definitely
Yes, somewhat



No
5

Contacted a health care professional
by telephone or in person.
Asked a family member or friend.
Used My HealtheVet to review my VA
health record information by using VA
Blue Button, viewing labs or other test
results, reading progress notes or my
VA Health Summary, and so on.
Used My HealtheVet Secure Messaging
to contact a VA health care professional.
Looked up information on the internet
using Google or a similar search tool
other than My HealtheVet.
Used some other method to answer
my question(s).
Did not get answers to my question(s).
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ABOUT YOU

36. In the last 12 months, have you used
the VA’s online patient portal, My
HealtheVet to do any of the following
tasks? Select all that apply.



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

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



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

Access your VA health records -- for
example, used VA Blue Button,
viewed labs, images, or other test
results, progress notes, or the VA
Health Summary.
Use Secure Messaging to
communicate with your VA
healthcare team.
Manage appointments - for example,
schedule an appointment or look up
future appointments.







Refill a prescription
Self-enter information such as
medication information, blood pressure,
blood sugar or other health information.
I have used My HealtheVet, but not
in the last 12 months. If Not used
in last 12 months, go to #38






Good
Fair
Poor

Gotten much better
Gotten better
Stayed about the same
Gotten worse
Gotten much worse

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




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

I have never used My HealtheVet.
If Never used, go to #38
Not sure/Do not recall If Not sure,
go to #38

Excellent
Very Good
Good
Fair
Poor

41. During the last 6 months, my overall
mental or emotional health has:







In the last 12 months, I have used Secure
Messaging through My HealtheVet:



Very Good

39. During the last 6 months, my overall
health has:

37. In the last 12 months, did you ever use
Secure Messaging through My
HealtheVet instead of any of the
following to address your healthcare
needs? Select all that apply.



Excellent

Instead of calling my VA provider or
nurse on the phone
Instead of scheduling an in-person
visit with my VA provider

Gotten much better
Gotten better
Stayed about the same
Gotten worse
Gotten much worse

Instead of going physically to VA to
talk with someone other than my VA
provider
Instead of contacting or scheduling
an appointment with a community
(non-VA) provider
None of the above
I did not use Secure Messaging through
My HealtheVet in the last 12 months.
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IPS_SHEP_TH_SVY_ENG_12.20

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

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45. What language do you mainly speak at
home?

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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

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






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

No, Not Hispanic or Latino

44. What is your race? Mark one or more.
White



American Indian or Alaska Native  

Spanish
Chinese
Russian
Vietnamese
Portuguese
Some other language

46. What is your gender?

Yes, Hispanic or Latino






English

Black or African-American
Asian

Man
Woman
Transgender Man
Transgender Woman
Non-binary
Other

47. Do you consider yourself to be:

Native Hawaiian or other
Pacific Islander








Heterosexual or straight
Gay
Lesbian
Bisexual
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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Please do not write in this area.

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