Form VA Form 10-1465-3 VA Form 10-1465-3 SHEP Outpatient Long Form 10-1465-3

OMB Number 2900-0712
Est. Burden: 25 minutes
VA Form 10-1465-3

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
AMBULATORY CARE 2012
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 25 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: 31 - 1209

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
Î 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 Î 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 Î 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.

4.

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 Î If No, Go to Question 5
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?
Worst healthcare possible
† 0
† 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 Î 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 Î 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 Î 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 Î 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 Î 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

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 Î 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 Î If No, Go to Question 29

28. If you had any of the concerns listed above, 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.

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.

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

Fair

Good

Very
Good

Excellent

Does Not
Apply

a.

Cleanliness of the room

†

†

†

†

†

†

b.

Privacy while in the room

†

†

†

†

†

†

c.

Noise level

†

†

†

†

†

†

d.

Sense of safety and security

†

†

†

†

†

†

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

Fair

Good

Very
Good

Excellent

Does Not
Apply

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)?

†

†

†

†

†

†

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

†

†

†

†

†

†

e.

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

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 Î If No, Go to Question 42

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ABOUT YOU

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 Î Go to Question 39
† Patient advocate Î Go to Question 39
† Other VA staff Î Go to Question 39
† Did not report the complaint to a VA
employee

42. In general, how would you rate your overall
health?
† Excellent
† Very good
† Good
† Fair
† Poor

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

43. Have you had a flu shot since
September 1, 2009?
† Yes
† No
† Don’t know

44. If you did not get a flu vaccine in September
2009 or later, why not? Mark the MAIN
reason:
† Was told I was not eligible to get the flu
vaccine this year because of the shortage
† Flu vaccine not available and I didn't get it
elsewhere
† Medical advice not to get a flu shot (such
as allergy, illness)
† No time/Didn't get around to it
† Inconvenient to get it at the VA
† Don't like needles/injections
† I believe it might make me sick
† Don't believe in it/Prefer other methods of
prevention
† Did not think I needed a flu shot
† Did not want a flu vaccine
† I plan to get my flu vaccine at a later date
† Other

45. Where did you get your flu vaccine?
†
†
†
†
†
†

At the VA (such as a hospital, clinic,
outreach mobile unit)
Vet Center
Non-VA hospital, clinic, doctor's office,
visiting nurse or Health Department
Community source (drug store, church,
grocery store, etc.)
Other
Do not remember

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46. Have you ever had a pneumonia shot? This
shot is usually given only once or twice in a
person’s lifetime and is different from the flu
shot. It is also called the pneumococcal
vaccine.
† Yes
† No
† Don’t know

47. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
† Every day
† Some days
† Not at all Î If Not at all, Go to Question 51
† Don’t know Î If Don’t know, Go to Question 51

48. In the last 12 months, how often were you
advised to quit smoking or using tobacco by
a VA doctor or other VA health provider?
† Never
† Sometimes
† Usually
† Always

49. In the last 12 months, how often was
medication recommended or discussed by a
VA doctor or VA health provider to assist
you with quitting smoking or using tobacco?
Examples of medication are: nicotine gum,
patch, nasal spray, inhaler, or prescription
medication.
† Never
† Sometimes
† Usually
† Always

50. In the last 12 months, how often did your VA
doctor or VA health provider discuss or
provide methods and strategies other than
medication to assist you with quitting
smoking or using tobacco? Examples of
methods and strategies are: telephone
helpline, individual or group counseling, or
cessation program.
† Never
† Sometimes
† Usually
† Always

51. Do you take aspirin daily or every other
day?
† Yes
† No
† Don’t know

52. Do you have a health problem or take
medication that makes taking aspirin unsafe
for you?
† Yes
† No
† Don’t know

53. Has a VA doctor or VA health provider ever
discussed with you the risks and benefits of
aspirin to prevent heart attack or stroke?
† Yes
† No

54. Are you aware that you have any of the
following conditions? Check all that apply.
† High cholesterol
† High blood pressure
† Parent or sibling with heart attack before
the age of 60

55. Has a VA doctor ever told you that you have
any of the following conditions? Check all
that apply.
† A heart attack
† Angina or coronary heart disease
† A stroke
† Any kind of diabetes or high blood sugar

56. 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.
†
†
†
†
†
†

Never Î If Never, Go to Question 60
Monthly or less
2-4 times a month
2-3 times a week
4-5 times a week
6 or more times a week

8

57. How many drinks containing alcohol did you

61. During the past 4 weeks, have you had any of

have on a typical day when you were
drinking in the past 12 months?
† 0 drinks (Did not drink in the past 12
months) Î If 0, Go to Question 60
† 1-2 drinks
† 3-4 drinks
† 5-6 drinks
† 7-9 drinks
† 10 or more drinks

the following problems with your work or
other regular daily activities as a result of
your physical health?

58. How often did you have 6 or more drinks on

a.

†
†
†
†
†
b.

one occasion in the past 12 months?
† Never
† Less than monthly
† Monthly
† Weekly
† Daily or almost daily

59. 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)?
† Yes
† No

†
†
†
b.

Yes, limited a lot
Yes, limited a little
No, not limited at all

Climbing several flights of stairs?
†
†
†

Yes, limited a lot
Yes, limited a little
No, not limited at all

No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

62. 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)?
a.

Accomplished less than you would like
†
†
†
†
†

activities you might do during a typical day.
Does your health now limit you in these
activities? If so, how much?
Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or
playing golf?

No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

Were limited in the kind of work or other
activities?
†
†
†
†
†

60. The following two questions are about

a.

Accomplished less than you would like?

b.

No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

Didn't do work or other activities as carefully
as usual
†
†
†
†
†

No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time

63. During the past 4 weeks, how much did pain
interfere with your normal work (including
both work outside the home and
housework)?
† Not at all
† A little bit
† Moderately
† Quite a bit
† Extremely
9

64. How much of the time during the past 4 weeks:
All of the
time

Most of
the time

A good bit
of the time

Some of
the time

A little of
the time

None of
the time

a.

Have you felt calm and
peaceful?

†

†

†

†

†

†

b.

Did you have a lot of energy?

†

†

†

†

†

†

c.

Have you felt downhearted
and blue?

†

†

†

†

†

†

65. How much of the time during the past 4 weeks
has your physical health or emotional problems
interfered with your social activities (like visiting
with friends, relatives, etc.)?
† All of the time
† Most of the time
† Some of the time
† A little of the time
† None of the time

66. Have you been treated by a VA provider for
chronic pain in the past 12 months?
† Yes
† No

67. If you have been treated by a VA provider for
chronic pain, please rate the effectiveness of your
pain treatment?
† Poor
† Fair
† Good
† Very good
† Excellent

68. What is the highest grade or level of school that
you have completed?
† 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

69. Are you of Hispanic or Latino origin or descent?
†
†

Yes, Hispanic or Latino
No, Not Hispanic or Latino

70. What is your race? (Mark all that apply)
†
†
†
†
†
†

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

10

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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