JOES-7 Questionnaire 10-3-2024

Joint Outpatient Experience Survey

OMB CONTROL NUMBER: XXXX-XXXX

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, [Insert OMB Control Number], is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY STATEMENT

Providing information in this survey is voluntary. There is no penalty nor will your benefits be affected if you choose not to respond.

However, maximum participation is encouraged so that the data will be complete and representative. Your survey response will be treated as confidential, identifying information will be used only by persons engaged in, and for the purposes of, the survey research.

However, if during this survey you indicate a direct threat to harm yourself or others, we are required to forward information about that threat to appropriate authorities for action, which will likely include their contacting you.

Question 1: [ASK ALL]

Did your healthcare team begin to address your needs within 30 minutes of your appointment time?

Please select one answer

• Yes

• No

Question 2: [ASK ALL]

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

• Yes, definitely

• Yes, somewhat

• No

Question 3: [ASK ALL]

During your most recent visit, did [INSERT PROVIDER] spend enough time with you?

• Yes, definitely

• Yes, somewhat

• No

Question 4: [ASK ALL]

I trust the provider I saw on this visit to give me the care that I need

• Yes, definitely

• Yes, somewhat

• No

Question 4b: [ASK ONLY IF QUESTION 4 = NO]

What are the most important reasons why you do not trust the provider you saw on this visit?

Please do not provide any personally identifiable information, but please be as specific as possible.

Question 5: [ASK ALL]

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?

• 0 Worst visit possible

• 1

• 2

• 3

• 4

• 5

• 6

• 7

• 8

• 9

• 10 Best visit possible

Question 6: [ASK ALL]

Please indicate how much you agree or disagree with the following statement:

In general, I am able to see a provider when needed

• Strongly Disagree

• Somewhat Disagree

• Neither Agree nor Disagree

• Somewhat Agree

• Strongly Agree

Question 7: [ASK ALL]

Please provide any comments about this facility that you would like to share. Please do not provide any personally identifiable information.

[TO SHOW IN A LINK ON EACH WEBPAGE:]

PRIVACY STATEMENT

This statement serves to inform you of the purpose for collecting personal information as required by the Privacy Act of 1974, as amended, and how that information will be stored and used.

AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C., Ch. 55, Medical and Dental Care; 45 CFR 164, Security and Privacy; Department of Defense (DoD) Instruction 6015.23, Foreign Military Personnel Care and Uniform Business Offices in Military Treatment Facilities (MTFS); DoD Manual 6025.18, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs; and E.O. 9397 (SSN), as amended.

PURPOSE: The JOES Survey Suite is a survey system used by the military to gather feedback about outpatient care. The surveys help measure patient satisfaction and guide efforts to make the health system better.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: to contractors and others performing or working for the Federal Government when necessary to accomplish an agency function related to this System of Records; For a complete listing of the Routine Uses for this system, refer to the below hyperlinked SORN.

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Rules, as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

APPLICABLE SORN: EDHA 07, Military Health Information System (June 15, 2020; 85 FR 36190) https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/DHA/EDHA-07.pdf

DISCLOSURE: Voluntary, Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if you choose not to respond, although maximum participation is encouraged so the data will be complete and representative.