VA Form 10-1465-4 SHEP Ambulatory Care Short Form

OMB Number 2900-0712
Est. Burden:15 minutes
VA Form 10-1465-4

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
AMBULATORY CARE 2013
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.
We want to remind you that all information is strictly anonymous. It will not be shared with your doctor or affect
your VA care.
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 15 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.

*** YOUR RECENT VISIT TO A VA FACILITY ***
Our records show that you recently visited the VA facility described below. You will be asked to refer to this
information later in the survey:

Version: 32 – 0412

SURVEY INSTRUCTIONS
Answer all the questions by checking the box to the left of your answer. Make sure that your answer is marked inside the
box.
Please use blue or black ink pen, or pencil.
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 of this survey. This number is ONLY used to let us know if you returned your
survey.
YOUR VA HEALTH CARE IN
THE LAST 12 MONTHS

5.

In the last 12 months, not counting the times
you went to an emergency room, how many
times did you go to a doctor’s office or clinic to
get healthcare for yourself?
□ None
1
2
3
4
□ 5 to 9
□ 10 or more

6.

A health provider could be a general doctor, a
specialist doctor, a nurse practitioner, a
physician assistant, a nurse, or anyone else you
would see for health care. In the last 12 months,
how often did you and a VA doctor or other
health provider talk about specific things you
could do to prevent illness?
□ Never
□ Sometimes
□ Usually
□ Always

7.

Choices for your treatment or healthcare can
include choices about medicine, surgery, or
other treatment. In the last 12 months, did a
VA doctor or other health provider tell you
there was more than one choice for your
treatment or healthcare?
□ Yes
□ No 
If No, Go to Question 10

Please think about all of the healthcare you received from
the VA in the last 12 months.

1.

In the last 12 months, did you have an illness,
injury, or condition that needed care right away in
a clinic, emergency room, or doctor’s office?
□ Yes
□ No 
If No, Go to Question 3

2.

In the last 12 months, when you needed care right
away, how often did you get care as soon as you
thought you needed?
□ Never
□ Sometimes
□ Usually
□ Always

3.

In the last 12 months, not counting the times you
needed care right away, did you make any
appointments for your healthcare at a doctor’s
office or clinic?
□ Yes
□ No 
If No, Go to Question 5

4.

In the past 12 months, not counting the times you
needed care right away, how often did you get an
appointment as soon as you thought you needed?
□ Never
□ Sometimes
□ Usually
□ Always

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8.

9.

In the last 12 months, did a VA doctor or other
health provider talk with you about the pros and
cons of each choice for your treatment or
healthcare?
□ Definitely Yes
□ Somewhat Yes
□ Somewhat No
□ Definitely No
In the last 12 months, when there was more than
one choice for your treatment or healthcare, did a
VA doctor or other health provider ask which
choice was best for you?
□ Definitely Yes
□ Somewhat Yes
□ Somewhat No
□ Definitely No

10. Using any number from 0 to 10, where 0 is the
worst healthcare possible and 10 is the best
healthcare possible, what number would you use
to rate all your VA healthcare in the last 12
months?
□ 0
Worst healthcare possible
1
2
3
4
5
6
7
8
9
□ 10
Best healthcare possible

11. In the past 12 months, did you try to get any care,
tests or treatment through VA?
□ Yes
□ No 
If No, Go to Question 13

12. In the past 12 months, how often was it easy to
get the care, tests or treatment you thought you
needed through VA?
□ Never
□ Sometimes
□ Usually
□ Always
YOUR PERSONAL VA
DOCTOR OR NURSE

13. A personal doctor or nurse is the one you would
see if you need a checkup, want advice about a
health problem or get sick or hurt. Do you have
a personal VA doctor or nurse?
□ Yes
□ No 
If No, Go to Question 21

14. In the last 12 months, how many times did you
visit your personal VA doctor or nurse to get
care for yourself?
□ None 
If None, Go to Question 20
1
2
3
4
□ 5 to 9
□ 10 or more

15. In the last 12 months, how often did your
personal VA doctor or nurse explain things in a
way that was easy to understand?
□ Never
□ Sometimes
□ Usually
□ Always

16. In the last 12 months, how often did your
personal VA doctor or nurse listen carefully to
you?
□ Never
□ Sometimes
□ Usually
□ Always

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17. In the last 12 months, how often did you have a
hard time speaking with or understanding your
personal VA doctor or nurse because you spoke
different languages?
□ Never
□ Sometimes
□ Usually
□ Always

18. In the last 12 months, how often did your personal
VA doctor or nurse show respect for what you had
to say?
□ Never
□ Sometimes
□ Usually
□ Always

19. In the last 12 months, how often did your personal
VA doctor or nurse spend enough time with you?
□ Never
□ Sometimes
□ Usually
□ Always

20. Using any number from 0 to 10, where 0 is the
worst personal doctor/nurse possible and 10 is the
best personal doctor/nurse possible, what number
would you use to rate your personal VA
doctor/nurse?
0 Worst personal doctor/nurse possible
1
2
3
4
5
6
7
8
9
□ 10 Best personal doctor/nurse possible

GETTING HEALTH CARE FROM VA
SPECIALISTS

21. Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and
other doctors who specialize in one area of
healthcare. In the last 12 months, did you try
to make any appointments to see a VA
specialist?
□ Yes
□ No 
If No, Go to Question 25

22. In the last 12 months, how often was it easy to
get appointments with VA specialists?
□ Never
□ Sometimes
□ Usually
□ Always

23. How many VA specialists have you seen in the
last 12 months?
□ None 
If None, Go to Question 25
□ 1 VA specialist
2
3
4
□ 5 or more VA specialists

24. We want to know your rating of the VA
specialist you saw most often in the last 12
months. Using any number from 0 to 10, where
0 is the worst specialist possible and 10 is the
best specialist possible, what number would you
use to rate that VA specialist?
□ 0 Worst specialist possible
1
2
3
4
5
6
7
8
9
□ 10 Best specialist possible

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USING THE VA PHARMACY

28. If you had any of the concerns listed above,
25. During the past 2 months, how long did you
usually wait for your prescriptions to be filled at
the VA pharmacy?
□ 1 to 10 minutes
□ 11 to 20 minutes
□ 21 to 30 minutes
□ 31 to 40 minutes
□ More than 40 minutes
□ Did not wait at the VA pharmacy; I had my
prescriptions mailed to me
□ Didn’t use the VA pharmacy during the past
2 months 
If Didn’t Use, Go to Question 30

26. Have you had any concerns about VA pharmacy
services during the past 2 months?
□ Yes
□ No 
If No, Go to Question 29

27. What were your concerns about VA pharmacy
services during the past 2 months? (Please mark
all that apply)
□ I received the wrong medication through the
mail out program.
□ I received the wrong medication at the VA
pharmacy pick up window.
□ I received too large a supply of one or more
medications through the mail out program.
□ I received too large a supply of one or more
medications through the VA pharmacy pick up
window.
□ There was an unexplained change to the
medication I received through the mail out
program.
□ There was an unexplained change to the
medication I received through the VA pharmacy
pick up window.

did you know whom to contact?
□ Yes, and it was resolved
□ Yes, but it was not resolved
□ No, I did not know whom to contact

29. Overall, how would you rate VA
pharmacy services during the past 2
months?
□ Poor
□ Fair
□ Good
□ Very good
□ Excellent
YOUR RECENT VISIT TO A VA FACILITY
We realize that you may receive care at more than one
VA location. However, it is important that you answer
the following questions based on the facility and visit
date described on the front cover of this booklet.

30. What was the reason for your recent visit?
(You may choose more than one)
□ Routine physical
□ Routine follow-up
□ Flare-up of a long-term problem
□ Get help with a new problem
□ Prescription refill
□ Other

31. On the day of your appointment, how long did
you wait in line to check in?
□ No wait
□ 1 to 10 minutes
□ 11 to 20 minutes
□ 21 to 30 minutes
□ 31 to 60 minutes
□ More than 1 hour

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32. How long after the time when your
appointment was scheduled to begin did you
wait to be seen?
□ No wait
□ 1 to 10 minutes
□ 11 to 20 minutes
□ 21 to 30 minutes
□ 31 to 60 minutes
□ More than 1 hour
The following questions will help us understand your opinion regarding some characteristics of the VA facility described on
the front cover of this booklet:

33. How would you rate the following aspects of the examination or treatment room:
Poor
a.

Cleanliness of the room

b.

Privacy while in the room

c.

Noise level

d.

Sense of safety and security

Fair

Good

Very
Good

Excellent

Does Not
Apply

34. How would you rate the following aspects of the equipment and facilities:
Poor
a.

Cleanliness of the
reception/waiting area

b.

Cleanliness of the restroom/lavatory

c.

Availability of parking

d.

How would you rate the clinic building
overall (i.e., attractiveness of facility
appearance, quality of building
maintenance and upkeep)?

e.

In terms of your satisfaction, how
would you rate the convenience of the
location of the clinic facility?

35. All things considered, how satisfied were you with
the VA during your recent visit?
□ Completely satisfied
□ Very satisfied
□ Somewhat satisfied
□ Neither satisfied nor dissatisfied
□ Somewhat dissatisfied
□ Very dissatisfied
□ Completely dissatisfied

Fair

Good

Very
Good

Excellent

Does Not
Apply

ABOUT COMMUNICATING WITH VA

36. Did you have a complaint about how you
were treated (medically or personally)
during your recent healthcare visit?
□ Yes
□ No 
If No, Go to Question 42

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37. 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 39
□ Patient advocate 
Go to Question 39
□ Other VA staff 
Go to Question 39
□ Did not report the complaint to a VA employee

38. 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

39. 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

40. 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

41. How long did it take for the VA location 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:

42. I got the service I needed.







Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

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







Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

44. I felt like a valued customer.







Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

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







Strongly Disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

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

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

Yes, Hispanic or Latino
No, Not Hispanic or Latino

49. What is your race? Please choose one or more.

Excellent
Very good
Good
Fair
Poor

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

□
□

□
□
□
□
□

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

50. What language do you mainly speak at home?

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

□
□
□
□
□
□

English
Spanish
Chinese
Russian
Vietnamese
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.
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 Synovate
P.O. Box 806046
Chicago, IL 60680

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