Va 7

VA 7 10-21083c(1).pdf

REQUEST FOR APPROVAL OF PILOT OF THE HCAHPS/SHEP SATISFACTION SURVEY INSTRUMENTS, VA FORMS OF THE 10-21083(NR) SERIES

VA 7

OMB: 2900-0707

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OMB Number 2900-new
Est. Burden: 45 minutes
VA Form 10-21083c(NR)

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
RECENTLY DISCHARGED INPATIENT 2007

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 questionnaire. Your answers help ensure that all
veterans receive the highest quality care they have earned and so richly deserve.
We want to remind you that all information is strictly anonymous. It will not be shared with your doctor or affect
your VA care.
Please read each question and fill in the circle that best describes your experience. Use blue or black ink pen, or
pencil. Please be sure to read all pages of this booklet.

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 45 minutes. This includes
the time it will take to read instructions, gather the necessary facts and fill out the form.
Surveys of healthcare experiences are used to gauge customer perceptions of VA services as
well as gather information on patient's functional status and health behaviors. 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.

Please answer all survey questions about your hospitalization at:
Alpha VAMC ending on March 3, 2007.

Please answer the questions in this survey about this stay at Alpha VAMC on March 3, 2007. Do not
include any other hospital stay in your answers.

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YOUR CARE FROM NURSES
1. During this hospital stay, how often did nurses treat you with courtesy and respect?
E Never
E Sometimes
E Usually
E Always
2. During this hospital stay, how often did nurses listen carefully to you?
E Never
E Sometimes
E Usually
E Always
3. During this hospital stay, how often did nurses explain things in a way you could understand?
E Never
E Sometimes
E Usually
E Always
4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you
wanted it?
E Never
E Sometimes
E Usually
E Always
E I never pressed the call button
5. Using any number from 0 to 10 where 0 is the worst possible care and 10 is the best possible care, what
number would you give the care you got from all the nurses who treated you?
E 0 Worst possible nursing care
E 1
E 2
E 3
E 4
E 5
E 6
E 7
E 8
E 9
E 10 Best possible nursing care
YOUR CARE FROM DOCTORS

6. During this hospital stay, how often did doctors treat you with courtesy and respect?
E Never
E Sometimes
E Usually
E Always
7. During this hospital stay, how often did doctors listen carefully to you?
E Never
E Sometimes
E Usually
E Always
8. During this hospital stay, how often did doctors explain things in a way you could understand?
E Never
E Sometimes
E Usually
E Always

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9. Using any number from 0 to 10 where 0 is the worst possible care and 10 is the best possible care, what
number would you give the care you got from all the doctors who treated you?
E 0 Worst possible doctor care
E 1
E 2
E 3
E 4
E 5
E 6
E 7
E 8
E 9
E 10 Best possible doctor care
THE HOSPITAL ENVIRONMENT
10. During this hospital stay, how often were your room and bathroom kept clean?
E Never
E Sometimes
E Usually
E Always
11. During this hospital stay, how often was the area around your room quiet at night?
E Never
E Sometimes
E Usually
E Always
YOUR EXPERIENCES IN THIS HOSPITAL

12. During this hospital stay, did you need help from nurses or other hospital staff in getting to the
bathroom or in using a bedpan?
E Yes
E No > Go to Question 14
13. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
E Never
E Sometimes
E Usually
E Always
14. During this hospital stay, did you need medicine for pain?
E Yes
E No > Go to Question 17
15. During this hospital stay, how often was your pain well controlled?
E Never
E Sometimes
E Usually
E Always
16. During this hospital stay, how often did the hospital staff do everything they could to help you with your
pain?
E Never
E Sometimes
E Usually
E Always
17. During your hospital stay, did doctors, nurses, or other hospital staff ever ask if you were allergic to any
medicine?
E Yes
E No

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18. During this hospital stay, were you given any medicine that you had not taken before?
E Yes
E No > Go to Question 20
19. Before giving you the medicine, did hospital staff describe possible side effects in a way you could
understand?
E Yes
E No
WHEN YOU LEFT THE HOSPITAL
20. After you left the hospital, did you go directly to your own home, to someone else's home, or to another
health facility?
E Own home
E Someone else's home
E Another health facility > Go to Question 23
21. During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you
would have the help you needed when you left the hospital?
E Yes
E No
22. During this hospital stay, did you get information in writing about what symptoms or health problems to
look out for after you left the hospital?
E Yes
E No
OVERALL RATING OF HOSPITAL
Please answer the following questions about the stay at Alpha Hospital on March 3, 2005. Do not
include any other hospital stays in your answer.
23. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital
possible, what number would you use to rate this hospital during your stay?
E 0 Worst hospital possible
E 1
E 2
E 3
E 4
E 5
E 6
E 7
E 8
E 9
E 10 Best hospital possible
24. Would you recommend this hospital to your friends and family?
E Definitely no
E Probably no
E Probably yes
E Definitely yes

ABOUT YOU

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There are only a few remaining items left.

25. In general, how would you rate your overall health?
E Excellent
E Very Good
E Good
E Fair
E Poor
26. In general, how would you rate your overall mental or emotional health?
E Excellent
E Very Good
E Good
E Fair
E Poor
27. What is the highest grade or level of school that you have completed?
E 8th grade or less
E Some high school, but did not graduate
E High school graduate or GED
E Some college or 2-year degree
E 4-year college graduate
E More than 4-year college degree
28. Are you of Hispanic or Latino origin or descent?
E Yes, Hispanic or Latino
E No, not Hispanic or Latino
29. What is your race? Please choose one or more.
E White
E Black or African-American
E Asian
E Native Hawaiian or other Pacific Islander
E American Indian or Alaskan Indian or Alaskan Native
E Other (please print): _____________________
30. What language do you mainly speak at home?
E English
E Spanish
E Some other language (please print):_________________________
31. Did someone help you complete this survey?
E Yes > Go to Question 32
E No > Go to Question 33
32. How did that person help you? Check all that apply.
E Read the questions to me
E Wrote down the answers I gave
E Answered the questions for me
E Translated the questions into my language
E Helped in some other way
33. If you could change one thing about the hospital, what would it be? (Please print your answer on the
lines provided below.)

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About Your Most Recent VA Hospitalization 2005

***ADMISSION***
34. Was your hospital stay an emergency or planned in advance?
E Emergency
E Planned in advance
35. How organized was the admission process?
E Not at all organized
E Somewhat organized
E Very organized
36. During your admission did you get enough information about your medical condition and treatment?
E Yes, definitely
E Yes, somewhat
E No
E Did not want information
37. Do you feel you had to wait too long before you got to your room?
E Yes, definitely
E Yes, somewhat
E No
38. If you had to wait to go to your room, did someone from the hospital explain the reason for the delay?
E Yes
E No
E Did not have to wait
39. How would you rate the courtesy of the staff who admitted you?
E Poor
E Fair
E Good
E Very Good
E Excellent
***DOCTORS***

40. Was there one particular doctor in charge of your care in the hospital?
E Yes
E No
E Not sure
41. When you had important questions to ask a doctor, did you get answers you could understand?
E Yes, always
E Yes, sometimes
E No
E Did not have questions
42. If you had any anxieties or fears about your condition or treatment, did a doctor discuss them with you?
E Yes, completely
E Yes, somewhat
E No
E Did not have anxieties or fears
43. Did you have confidence and trust in the doctors treating you?
E Yes, always
E Yes, sometimes
E No

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44. Did doctors talk in front of you as if you weren't there?
E Yes, often
E Yes, sometimes
E No
45. How would you rate the availability of your doctors?
E Poor
E Fair
E Good
E Very Good
E Excellent
***NURSES***
46. When you had important questions to ask a nurse, did you get answers you could understand?
E Yes, always
E Yes, sometimes
E No
E Did not have questions
47. If you had any anxieties or fears about your condition or treatment, did a nurse discuss them with you?
E Yes, completely
E Yes, somewhat
E No
E Did not have anxieties or fears
48. Did you have confidence and trust in the nurses treating you?
E Yes, always
E Yes, sometimes
E No
49. Did nurses talk in front of you as if you weren't there?
E Yes, often
E Yes, sometimes
E No
50. How would you rate the courtesy of your nurses?
E Poor
E Fair
E Good
E Very Good
E Excellent
51. How would you rate the availability of your nurses?
E Poor
E Fair
E Good
E Very Good
E Excellent
***HOSPITAL STAFF***

52. Did you have trouble understanding the provider because of a language problem?
E Yes, definitely
E Yes, somewhat
E No
53. Sometimes in the hospital, one doctor or nurse will say one thing and another will say something quite
different. Did this happen to you?
E Yes, always
E Yes, sometimes
E No

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54. Did a doctor or nurse explain the results of tests in a way you could understand?
E Yes, completely
E Yes, somewhat
E No
E No tests were done
55. Was personal information about you treated in a confidential manner?
E Yes, always
E Yes, sometimes
E No
56. Did you have enough say about your treatment?
E Yes, definitely
E Yes, somewhat
E No
57. Did your family or someone else close to you have enough chances to talk to your doctor?
E Yes, definitely
E Yes, somewhat
E No
E No family or friends involved
E Family did not want or need information
58. How much information about your condition or treatment was given to your family or someone close to
you?
E Not enough
E Right amount
E Too much
E No family or friends involved
E Family did not want or need information
59. Was it easy for you to find someone on the hospital staff to talk to about your concerns?
E Yes, definitely
E Yes, somewhat
E No
E Did not want to talk/no concerns
60. Did you have enough privacy?
E Yes
E No
61. When you needed help eating, bathing, or getting to the bathroom, did you get it in time?
E Yes, always
E Yes, sometimes
E No
E Did not need help
62. How many minutes after you used the call button did it usually take before you got the help you needed?
E 0 to 5 minutes
E 6 to 10 minutes
E 11 to 15 minutes
E 16 to 30 minutes
E More than 30 minutes
E Never got help
E Never used call button
E No call button available
63. When you had pain, was it usually severe, moderate, or mild?
E Severe
E Moderate
E Mild
E Did not have pain

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64. How many minutes after you asked for pain medicine did it usually take before you got it?
E 0 to 5 minutes
E 6 to 10 minutes
E 11 to 15 minutes
E 16 to 30 minutes
E More than 30 minutes
E Never got pain medicine
E Never asked for pain medicine
E Didn't have pain
65. Do you think that the hospital staff did everything they could to help control your pain?
E Yes, definitely
E Yes, somewhat
E No
E Didn't have pain
66. Overall, how much pain medicine did you get?
E Not enough
E Right amount
E Too much
E Didn't have pain
67. Sometimes people who are in pain don't ask for pain medication. Was this true for you?
E Yes
E No
E Did not have pain
68. If you answered yes to the question above, was it because...
E You were concerned it might be habit forming
E A patient should expect to put up with some pain
E You felt it would be a bother if you asked for it
E No one told you pain medication was available
E You were concerned about possible side effects
E You were concerned about what might happen if you mixed pain medications with your other
medication
E Other
69. Did you feel like you were treated with respect and dignity while you were in the hospital?
E Yes, always
E Yes, sometimes
E No
70. Did you feel that you were treated like a second class citizen?
E Yes
E No
Your Room
70a. cleanliness of your room
E Poor
E Fair
E Good
E Very Good
E Excellent
E Does Not Apply
70b. privacy in your room
E Poor
E Fair
E Good
E Very Good
E Excellent
E Does Not Apply

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Your Room
70c. noise level
E Poor
E Fair
E Good
E Very Good
E Excellent
E Does Not Apply
70d. sense of safety and security
E Poor
E Fair
E Good
E Very Good
E Excellent
E Does Not Apply
Equipment and Facilities
70a. ease of finding your way around the hospital
E Poor
E Fair
E Good
E Very Good
E Excellent
E Does Not Apply
70b. availability of parking
E Poor
E Fair
E Good
E Very Good
E Excellent
E Does Not Apply
70c. cost of parking
E Poor
E Fair
E Good
E Very Good
E Excellent
E Does Not Apply
***GOING HOME***

71. Did someone on the hospital staff explain the purpose of the medicines you were to take at home in a
way you could understand?
E Yes, completely
E Yes, somewhat
E No
E Did not need explanation
E No medicines at home
72. Did someone on the hospital staff tell you about medication side effects to watch for when you went
home?
E Yes, completely
E Yes, somewhat
E No
E Did not need explanation
E No medicines at home

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73. Did someone on the hospital staff tell you about what problems about your illness or operation to watch
for after you went home?
E Yes, completely
E Yes, somewhat
E No
74. Did someone on the hospital staff tell you what activities you could do after you got home (such as
driving, walking up steps, lifting, sex)?
E Yes, completely
E Yes, somewhat
E No
75. Did the hospital staff give your family or someone close to you all the information they needed to help
you recover after you got home?
E Yes, definitely
E Yes, somewhat
E No
E No family or friends involved
E Family did not want or need information
76. Did you know who to contact if you needed medical advice or help right away, after you went home?
E Yes, always
E Yes, sometimes
E No
***OVERALL IMPRESSIONS***
77. How would you rate how well the doctors and nurses worked together?
E Poor
E Fair
E Good
E Very Good
E Excellent
E Do not know
78. Overall, how would you rate the quality of care you received at the hospital?
E Poor
E Fair
E Good
E Very Good
E Excellent
79. If you could have free care outside the VA, would you choose to be hospitalized here again?
E Definitely would not
E Probably would not
E Probably would
E Definitely would

80. How would you rate your health now?
E Poor
E Fair
E Good
E Very Good
E Excellent

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81. Have you ever complained to someone about the care that you got during your most recent
hospitalization? (You may choose more than one.)
E Yes, to a patient representative
E Yes, to some other official in the medical center
E Yes, to an official outside the medical center
E Yes, to a family member or friend
E Had a complaint but did not report it
E Had no complaints
If you spoke to either a patient representative or an official insider or outside the VA hospital, please
answer the following four (4) questions.
82. On a 5 point scale (where 1 = Very easy and 5 = Very difficult) how easy or difficult was it for you to find
someone to hear your complaint? (Fill in only one circle)
E 1 Very Easy
E 2
E 3
E 4
E 5 Very Difficult
E Not applicable
83. How long is it reasonable to wait for a complaint like yours to be resolved?
E Same day
E 2-7 days
E 8-14 days
E 15-21 days
E More than 21 days
84. Was your complaint or problem settled to your satisfaction?
E Yes
E No
E Did not report a complaint
85. How long did it take for the VA hospital to resolve your complaint?
E Same day
E 2-7 days
E 8-14 days
E 15-21 days
E More than 21 days
E Am still waiting for it to be settled
***ABOUT YOUR HEALTH***
Instructions: The following questions ask for your views about your health. Please answer every
questions by filling in one circle for each answer. If you are unsure about how to answer a question,
please give the best answer you can.

86. In general, would you say your health is...
E Excellent
E Very Good
E Good
E Fair
E Poor

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B

The following two questions are about activities you might do during a typical day. Does
your health now limit you in these activities? If so, how much?
86a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?
E Yes, Limited A Lot
E Yes, Limited A Little
E No, Not Limited At All
86b. Climbing several flights of stairs?
E Yes, Limited A Lot
E Yes, Limited A Little
E No, Not Limited At All
During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of your physical health?
86c. Accomplished less than you would like
E No, none of the time
E Yes, a little of the time
E Yes, some of the time
E Yes, most of the time
E Yes, all of the time
86d. Were limited in the kind of work or other activities
E No, none of the time
E Yes, a little of the time
E Yes, some of the time
E Yes, most of the time
E Yes, all of the time
During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of any emotional problems (such as feeling depressed or
anxious)?
86e. Accomplished less than you would like
E No, none of the time
E Yes, a little of the time
E Yes, some of the time
E Yes, most of the time
E Yes, all of the time
86f. Didn't do work or other activities as carefully as usual
E No, none of the time
E Yes, a little of the time
E Yes, some of the time
E Yes, most of the time
E Yes, all of the time
87. During the past 4 weeks, how much did pain interfere with your normal work (including both work
outside the home and housework)?
E Not at all
E A little bit
E Moderately
E Quite a bit
E Extremely

These three questions are about how you feel and how things have been with you during the past four
(4) weeks:

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How much of the time during the past 4 weeks:
87a. Have you felt calm and peaceful?
E All of the time
E Most of the time
E A good bit of the time
E Some of the time
E A little of the time
E None of the time
87b. Did you have a lot of energy?
E All of the time
E Most of the time
E A good bit of the time
E Some of the time
E A little of the time
E None of the time
87c. Have you felt downhearted and blue?
E All of the time
E Most of the time
E A good bit of the time
E Some of the time
E A little of the time
E None of the time
88. During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities (like visiting with friends, relatives, etc.)?
E All of the time
E Most of the time
E A good bit of the time
E Some of the time
E A little of the time
E None of the time
Now we'd like to ask you some questions about how your health may have changed.

89. Compared to one year ago, how would you rate your physical health in general now?
E Much better
E Somewhat better
E About the same
E Somewhat worse
E Much worse
90. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious,
depressed or irritable) now?
E Much better
E Somewhat better
E About the same
E Somewhat worse
E Much worse
91. How much of the time during the past week, did you feel depressed?
E Rarely or none of the time (less than 1 day)
E Some or a little of the time (1-2 days)
E Occasionally or a moderate amount of the time (3-4 days)
E Most or all of the time (5-7 days)

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92. In the past year, have you had 2 weeks or more when you felt sad, blue or depressed or when you lost
interest or pleasure in things that you usually cared about or enjoyed?
E Yes
E No
93. Have you had 2 years or more in your life when you felt depressed or sad most days, even if you felt
okay sometimes?
E Yes
E No
94. Have you been treated by a VA provider for chronic pain in the past 12 months?
E Yes
E No
95. If you have been treated by a VA provider for chronic pain, please rate the effectiveness of your pain
treatment?
E Poor
E Fair
E Good
E Very Good
E Excellent
***OTHER QUESTIONS ABOUT YOU***
Please answer the following questions. We want to remind you that all information is strictly
confidential. It will not be shared with your doctor or affect your VA care.
96. Are you of Hispanic or Latino origin or descent?
E Yes, I am Hispanic or Latino
E No, I am not
97. What is your race? (mark all that apply)
E White (Caucasian)
E Black or African American
E Asian
E Native Hawaiian or Pacific Islander
E American Indian or Alaska Native
98. What is the last year of school you have completed?
E Did not complete high school
E High school graduate or GED
E Some college
E College graduate or beyond
99. What is your current marital status?
E Married
E Divorced
E Separated
E Widowed
E Never married
100. Are you currently...
E Employed for wages
E Self-employed
E Unable to work
E Looking for work and unemployed for more than 1 year
E Looking for work and unemployed for less than 1 year
E Homemaker
E Student
E Retired

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101. What was your total household income (income from all sources) during the past 12 months?
E $15,000 or less
E $15,001 to $30,000
E $30,001 to $60,000
E $60,001 or more
102. How tall are you without shoes on? (Fill in feet (ft.) and inches (in.)) (If 1/2" round up)
E 5ft 0in or less
E 5ft 1in
E 5ft 2in
E 5ft 3in
E 5ft 4in
E 5ft 5in
E 5ft 6in
E 5ft 7in
E 5ft 8in
E 5ft 9in
E 5ft 10in
E 5ft 11in
E 6ft 0in
E 6ft 1in
E 6ft 2in
E 6ft 3in or more
103. How much do you weigh? (in pounds) (Fill in one)
E 90 lbs. or less
E 91-100 lbs.
E 101-110 lbs.
E 111-120 lbs.
E 121-130 lbs.
E 131-140 lbs.
E 141-150 lbs.
E 151-160 lbs.
E 161-170 lbs.
E 171-180 lbs.
E 181-190 lbs.
E 191-200 lbs.
E 201-210 lbs.
E 211-220 lbs.
E 221-230 lbs.
E 231-240 lbs.
E 241-250 lbs.
E 251-260 lbs.
E 261-270 lbs.
E 271-280 lbs.
E 281-290 lbs.
E 291-300 lbs.
E 301-310 lbs.
E 311 lbs. and over
104. During the past 12 months, have you been seen by...(fill in one)
E VA providers only
E Non-VA providers only
E VA and non-VA providers
E No providers

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105. Do you have one person who you think of as your regular doctor?
E Yes, a VA doctor
E Yes, a non-VA doctor
E No
106. Do you have Medicare coverage? (mark all that apply) Medicare is a federal health program for seniors
over 65 and certain younger disabled people.
E Yes, for hospital care (Part A)
E Yes, for doctor office visits (Part B)
E Yes, for the Medicare+Choice or HMO plan (Part C)
E No, I have no Medicare coverage
107. Do you have Medicaid? Medicaid is a state-run health insurance program for people whose income is
below a certain level.
E Yes
E No
108. Do you have any other health insurance coverage? (mark all that apply)
E Yes, a Medigap policy
E Yes, other private health insurance
E No, I have no other insurance

***QUESTIONS ABOUT YOUR HEALTH BEHAVIORS***

108a.How often do you take aspirin?
E Every day
E Every other day
E Occasionally
E Never
108b.If you take aspirin, do you take it to...(mark all that apply)
E Relieve Pain
E Reduce chance of heart attack or stroke
E Other
109. Have you ever smoked cigarettes?
E Yes, still smoking every day
E Yes, still smoking some days
E Yes, but no longer smoke at all
E No, never smoked (Go to #92)
110. If you used to smoke but no longer do so, about how long has it been since you last smoked cigarettes
at all?
E Less than 1 month
E 1-5 months
E 6-12 months
E 1-5 years
E More than 5 years (Go to #92)
111. On the average, about how many cigarettes a day do you now smoke? (If you no longer smoke at all,
indicate the number of cigarettes per day when you last smoked)
E None, never smoked
E Less than 10
E 10-20
E 21-40
E More than 40

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112. In the past 12 months have you stopped smoking for 1 day or longer because you were trying to quit
smoking?
E Yes
E No
In the past 12 months, has a VA doctor or other VA health care provider...
112a.Asked if you were interested in stopping smoking?
E Yes
E No
112b.Recommended that you be treated for smoking or offered to treat you themselves?
E Yes
E No
112c.Recommended that you use medications (e.g., nicotine patch, Zyban) to help you stop smoking?
E Yes
E No
113. During the past 12 months were you treated for smoking by a VA provider or in a VA treatment
program?
E Yes, VA provider
E Yes, VA treatment program
E Yes, both VA provider and VA treatment program
E No
113a.If you were treated for smoking by a VA provider or in a VA treatment program during the past 12
months, what services were recommended or offered to you? (Mark all that apply)
E Self-help materials
E Nicotine replacement medication (patch, gum, nasal spray or inhaler)
E Zyban, an antismoking medication (also called Bupropion or Welbutrin)
E Individual counseling
E Group counseling
E Telephone counseling
113b.Which of these anti-smoking services did you receive from a VA provider or a VA treatment program
during the past 12 months? (Mark all that apply)
E Self-help materials
E Nicotine replacement medication (patch, gum, nasal spray or inhaler)
E Zyban, an antismoking medication (also called Bupropion or Welbutrin)
E Individual counseling
E Group counseling
E Telephone counseling
113c.How long ago were you last treated for smoking by a VA provider or in a VA treatment program?
E Less than one month
E 1-5 months
E 6-12 months
113d.How much have you smoked since receiving this treatment?
E Have not smoked since receiving treatment
E Smoked less since receiving treatment
E Same as before
E Smoked more since receiving treatment
114. How often did you have a drink containing alcohol in the past 12 months? Consider a "drink" to be a
can or bottle of beer, a glass of wine, a wine cooler, or one cocktail or a shot of hard liquor (like scotch,
gin or vodka). Please mark only one.
E Never
E Monthly or less
E 2-4 times a month
E 2-3 times a week
E 4-5 times a week
E 6 or more times a week
B

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115. How many drinks containing alcohol did you have on a typical day when you were drinking in the past
12 months?
E 0 drinks (Did not drink in the past 12 months)
E 1-2 drinks
E 3-4 drinks
E 5-6 drinks
E 7-9 drinks
E 10 or more drinks
116. How often did you have 6 or more drinks on one occasion in the past 12 months?
E Never
E Less than monthly
E Monthly
E Weekly
E Daily or almost daily
117. In the past 12 months has a VA doctor or other VA health care provider advised you about your drinking
(to drink less or not to drink alcohol)?
E Yes
E No
118. In the past 12 months has a VA doctor or other VA health care provider referred you for help with your
drinking, either to professional treatment or to a self-help group such as AA?
E Yes
E No
119. Have you ever received professional treatment or attended self-help meetings (such as AA) for your
drinking?
E Yes, during the past 12 months
E Yes, but not during the past 12 months
E No

***RELIGIOUS/SPIRITUAL NEEDS***
120. My religious/spiritual needs are an important part of my overall care.
E Yes
E No
E Not applicable
121. I was asked if I had any religious/spiritual needs during my stay.
E Yes
E No
E Not applicable
122. My religious/spiritual needs were appropriately assessed and addressed.
E Yes
E No
E Not applicable
123. Literature in keeping with my faith was offered to me.
E Yes
E No
E Not applicable

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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
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:

Office of Quality and Performance Data Center
C/O National Research Corporation
P.O. Box 82660
Lincoln, NE 68501-2660

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File Type	application/pdf
File Modified	2008-01-25
File Created	2007-06-28