JOES-Dental Survey_10.4.2024

Joint Outpatient Experience Survey - Dental

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:

According to our records, you recently had a dental visit with [INSERT PROVIDER] on [INSERT VISIT DATE] at [INSERT FACILITY NAME]. Is this correct?

Please select one answer

Yes

No, saw someone else (Specify)_____

No, didn’t have visit / Did not keep appointment

Question 2:

What was the MAIN purpose of this visit?

Exam Only

Cleaning Only

Exam & Cleaning Only

Emergency Care or Sick Call

General Dentistry (Fillings)

Oral Surgery

Endodontics (Root Canal)

Periodontics (Gums)

Prosthodontics (Crowns/Bridges)

Orthodontics (Braces)

Orofacial Pain (TMJ, etc.)

Pediatric Dentistry

Other

Questions 3 to 5:

Thinking about your most recent visit to see [INSERT PROVIDER], did this dentist:

Please select only one answer for each item

Yes, definitely

Yes, somewhat

No

Treat you with courtesy and respect

Explain things in a way that was easy to understand

Seem to have the dental information they needed about you

Question 6:

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 with this dentist?

Please select one answer

0 Worst visit possible with this dentist

1

2

3

4

5

6

7

8

9

10 Best visit possible with this dentist

Not applicable/Does not apply

Question 7:

Please provide any comments about your visit with the dentist that you would like to share. Please do not provide any personally identifiable information.

Question 8:

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

Please select one answer

0 Worst care possible from this hygienist

1

2

3

4

5

6

7

8

9

10 Best care possible from this hygienist

Not applicable/Does not apply

Question 9:

If you made an appointment for this visit, how did you make this appointment?

Please select one answer

Phone

Patient Portal (Tricare Online, MHS GENESIS Patient Portal)

In Person

No, did not make appointment (ER, walk-in, someone else made appointment for me, etc.)

Question 10:

When making this appointment, were you at any time told no appointments were available but to call back when they would be available?

Please select one answer

Yes

No

Questions 11 to 13:

Please rate the following aspects of your appointment:

Please select only one answer for each item

Poor

Fair

Good

Very Good

Excellent

N/A

The ease of making the appointment

The amount of time between when you made the appointment until your actual visit

If seen past your scheduled appointment time, the effort made to keep you informed about the delay

Question 14:

Did your most recent visit start on time?

Please select one answer

Yes, definitely

Yes, somewhat

No

Question 15:

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

Please select one answer

Yes, definitely

Yes, somewhat

No

Question 16:

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

Please select one answer

Yes, definitely

Yes, somewhat

No

Question 17:

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

Please select one answer

0 Worst dental care possible on this visit

1

2

3

4

5

6

7

8

9

10 Best dental care possible on this visit

Questions 18 to 19:

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

Please select only one answer for each item

Strongly Disagree

Somewhat Disagree

Neither Agree nor Disagree

Somewhat Agree

Strongly Agree

I would recommend this facility to a TRICARE-eligible family member or friend

In general, I am able to see my dentist when needed

Question 20:

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

Please select one answer

Yes, definitely

Yes, somewhat

No

Question 21:

In general, how would you rate your overall dental health?

Please select one answer

Poor

Fair

Good

Very Good

Excellent

Question 22:

Please provide any comments about the 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.