Form VA Form 10-0503 VA Form 10-0503 Survey of Healthcare Experiences of Patients, Dental Pat

SURVEY OF HEALTHCARE EXPERIENCES OF PATIENTS
DENTAL &$5(
VA Form 10-0503
(VWLPDWHG%XUGHQPLQXWHV
OMB Number 2900-XXXX
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.

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 nonidentifying 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.

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 on page 1
No

Patient Satisfaction Survey – Print Version – 3/17/10

Page 2

1.

In the last 12 months, did you go to a VA
dentist’s office or clinic for care?
1
2

Yes
No  If No, please stop and
return this survey in the
postage-paid envelope.
Thank you.

About Your Health
2.

4.

2
3
4
5

Excellent
Very good
Good
Fair
Poor

2

5.

2

6.

2
3
4
5

Excellent
Very good
Good
Fair
Poor

2
3
4

Never
Sometimes
Usually
Always

In the last 12 months, how often did your
regular VA dentist listen carefully to you?
1
2
3
4

Patient Satisfaction Survey – Print Version – 3/17/10

Yes
No, I’ve seen someone else  If No,
go to #11

In the last 12 months, how often did your
regular VA dentist explain things in a way
that was easy to understand?
1

7.

Yes
No  If No, go to #11

Have you seen your regular VA dentist in
the last 12 months?
1

In general, how would you rate your overall
health?
1

A regular dentist is one you would go to for
check-ups and cleanings or when you have
a cavity or tooth pain. Do you have a
regular VA dentist?
1

In general, how would you rate the overall
condition of your teeth and gums?
1

3.

Your Regular Dentist

Never
Sometimes
Usually
Always

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8.

In the last 12 months, how often did your
regular VA dentist treat you with courtesy
and respect?
1
2
3
4

9.

Never
Sometimes
Usually
Always

In the last 12 months, how often did your
regular VA dentist spend enough time with
you?
1
2
3
4

Never
Sometimes
Usually
Always

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

Patient Satisfaction Survey – Print Version – 3/17/10

Your Dental Care in the Last 12
Months
So far, the questions on this survey have been
about your regular VA dentist. The next set of
questions asks about all dental care you had in
VA in the last 12 months.
11. In the last 12 months, how often did the
dentists or dental staff do everything they
could to help you feel as comfortable as
possible during your dental work?
1
2
3
4

Never
Sometimes
Usually
Always

12. In the last 12 months, how often did the
dentists or dental staff explain what they
were doing while treating you?
1
2
3
4

Never
Sometimes
Usually
Always

13. In the last 12 months, how often were your
dental appointments as soon as you
wanted?
1
2
3
4

Never
Sometimes
Usually
Always

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14. If you needed to see a dentist right away
because of a dental emergency in the last 12
months, did you get to see a dentist as soon
as you wanted?
0
1
2
3
4

I did not have a dental emergency in
the last 12 months
Definitely yes
Somewhat yes
Somewhat no
Definitely no

15. If you were advised to get an appointment
for yourself with a dentist who specializes
in a particular type of dental care (such as
root canals or gum disease) in the last 12
months, how often did you get an
appointment as soon as you wanted?
0

1
2
3
4

I did not try to get an appointment
with a specialist dentist for myself in
the last 12 months
Never
Sometimes
Usually
Always

16. In the last 12 months, how often did you
have to spend more than 15 minutes in the
waiting room before you saw someone for
your appointment?
1
2
3
4

17. If you had to spend more than 15 minutes in
the waiting room before you saw someone
for your appointment, how often did
someone tell you why there was a delay or
how long the delay would be?
1
2
3
4

Never
Sometimes
Usually
Always

18. 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 all of the VA dental
care you personally received in the last 12
months?
0 Worst dental care possible
1
2
3
4
5
6
7
8
9
10 Best dental care possible

Never  If Never, go to #18
Sometimes
Usually
Always

Patient Satisfaction Survey – Print Version – 3/17/10

Page 5

19. The next question asks about your VA
dental care and how up-to-date or state-ofthe-art you consider that care to be. Using
any number from 0 to 10, where 0 is very
dated or not current, and 10 is very
advanced or up-to-date, what number
would you use to rate all of the dental care
you personally received at the VA in the
last 12 months?
0 Not at all current or up-to-date
1
2
3
4
5
6
7
8
9
10 Very advanced or up-to-date
20. A dental provider could be a general dentist,
a dental specialist, a dental hygienist, or a
dental assistant. In the last 12 months, how
often did you and a VA dental provider talk
about specific things you could do to
prevent dental problems?
1
Never
2
Sometimes
3
Usually
4
Always

Patient Satisfaction Survey – Print Version – 3/17/10

21. Sometimes there can be different options in
dental care for your dental treatment or
preventive dental care. In the last 12
months, did a VA dental provider tell you
there was more than one choice for your
dental treatment or care?
1
Yes
2
No  If No, go to #24.
22. In the last 12 months, did a VA dental
provider talk with you about the pros and
cons of each choice for your dental
treatment or care?
1
2
3
4

Definitely yes
Somewhat yes
Somewhat no
Definitely no

23. In the last 12 months, when there was more
than one choice for your dental treatment or
care, did a VA dental provider ask which
choice was best for you?
1
2
3
4

Definitely yes
Somewhat yes
Somewhat no
Definitely no

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24. What was the main reason for your recent
visit? (You may choose more than one.)
1
2
3

4
5

Routine cleaning, check-up or
examination
Something was wrong, hurting or
bothering me
Treatment of a problem my dentist
discovered at an earlier check-up or
examination
Don’t know / don’t remember
Other

Patient Satisfaction Survey – Print Version – 3/17/10

25. In the last 12 months, how often did you
have a hard time speaking with or
understanding your VA dental provider
because you spoke different languages?
1
2
3
4

Never
Sometimes
Usually
Always

Page 7

The following questions will help us understand your opinion regarding some characteristics of the VA
facility described on the front cover of this booklet:
26.

How would you rate the following aspects of the dental examination or dental treatment room:
Poor

a. Cleanliness of the room

1

b. Privacy while in the room

1

c. Noise level

1

d. Sense of safety and security

1

27.

Fair

□
□
□
□

2
2
2
2

Good

□
□
□
□

3
3
3
3

□
□
□
□

Very
Good
4
4
4
4

□
□
□
□

Excellent
5
5
5
5

□
□
□
□

Does Not
Apply
6
6
6
6

□
□
□
□

How would you rate the following aspects of the dental 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?

1
1
1

□
□
□

Fair
2
2
2

□
□
□

Good
3
3
3

□
□
□

Very
Good
4
4
4

□
□
□

Excellent
5
5
5

□
□
□

Does Not
Apply
6
6
6

□
□
□

1

□

2

□

3

□

4

□

5

□

6

□

1

□

2

□

3

□

4

□

5

□

6

□

Patient Satisfaction Survey – Print Version – 3/17/10

Page 8

Dental Coverage and Eligibility

About You

The next question asks about your dental
coverage or eligibility within VA. Answer only
about your VA dental coverage and eligibility.

29. What is your age?

28. In the last 12 months, how often did your
VA dental coverage or eligibility cover all
of the dental services you thought should be
covered?
1
2
3
4

Never
Sometimes
Usually
Always

1
2
3
4
5
6
7

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

30. Are you male or female?
1
2

Male
Female

31. What is the highest grade or level of school
that you have completed?
1
2
3
4
5
6

Patient Satisfaction Survey – Print Version – 3/17/10

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

Page 9

32. Are you of Hispanic or Latino origin or
descent?
1
2

Yes, Hispanic or Latino
No, not Hispanic or Latino

34. Did someone help you complete this
survey?
1
2

33. What is your race? Please mark one or
more.
1
2
3
4
5

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

Yes
No  Thank you.
Please return the completed
survey in the postage-paid
envelope.

35. How did that person help you? Check all
that apply.
1
2
3
4
5

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way
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 veteran’s 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 XXXXXX
P.O. Box 806046
Chicago, IL 60680

Patient Satisfaction Survey – Print Version – 3/17/10

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