VA Form 10-1465-5 Clinician and Group Survey , Patient Centered Medical Ho

OMB Number 2900-0712
Est. Burden: 20 minutes
VA Form 10-1465-5

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS 2012

Clinician & Group Survey Patient Centered Medical Home, short form
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.
Your Privacy is Protected. All information that would let someone identify you or your family will be kept private.
Synovate will not share your personal information with anyone without your OK. Your responses to this survey are also
completely private to the extent permitted by law.
Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to, this will not affect the
health care you receive.
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 20 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.

Version: 44 – 1111

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
 If No, Go to Question 1
CARE FROM YOUR REGULAR VA
PROVIDER IN THE LAST 12 MONTHS

YOUR VA PROVIDER
A healthcare provider could be a general doctor, a nurse
practitioner, or a physician assistant.
1.

These questions ask about your own health care. Do not
include care you received when you stayed overnight in a
hospital. Do not include the times you went for dental
care visits.

Our records show that you received care from the
provider named below.
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4.

In the last 12 months, how many times did you
visit this provider to obtain care for yourself?
 None
 1 time
 2
 3
 4
 5 to 9
 10 or more times

5.

In the last 12 months, did you phone this
provider’s office to schedule an appointment for an
illness, injury or condition that needed care right
away?
 Yes
 No  If No, Go to Question 7

6.

In the last 12 months, when you phoned this
provider’s office to schedule an appointment for care
you needed right away, how often did you schedule
an appointment as soon as you needed?
 Never
 Sometimes
 Usually
 Always

7.

In the last 12 months, how many days did you
usually have to wait for an appointment when you
needed care right away?
 Same day
 1 day
 2 to 3 days
 4 to 7 days
 More than 7 days

Is that right?
 Yes
 No
2.

Is the provider named in Question 1 your regular
VA provider, the one you usually see if you need a
check-up, want advice about a health problem, or are
sick or hurt?
 Yes, this is my regular VA provider
 No, this is not my regular VA provider
 I do not have a regular VA provider  If you
do not have a regular VA provider, Go to
Question 47 on Page 6

The Questions In This Survey Will Refer To Your
Regular VA Provider – The One You Usually See When
You Come To VA.
Please Think Of That Person As You Answer The Survey.
3.

How long have you been going to this provider?
 Less than 6 months
 At least 6 months but less than 1 year
 At least 1 year but less than 3 years
 At least 3 years but less than 5 years
 5 years or more

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8.

In the last 12 months, did you make any
appointments for a check-up or routine care with
this provider?
 Yes
 No  If No, Go to Question 10

15. In the last 12 months, did you phone this
provider’s office with a medical question after
regular office hours?
 Yes
 No  If No, Go to Question 17

9.

In the last 12 months, when you made an
appointment for a check-up or routine care with
this provider, how often did you schedule an
appointment as soon as you needed?
 Never
 Sometimes
 Usually
 Always

16. In the last 12 months, when you phoned this
provider’s office after regular office hours, how
often did you receive an answer to your medical
question as soon as you needed?
 Never
 Sometimes
 Usually
 Always

10. Did this provider’s office give you information
about what to do if you needed care during
evenings, weekends, or holidays?
 Yes
 No

17. In the last 12 months, did you use e-mail,
MyHealtheVet, or secure messaging to contact this
provider’s office with a medical question?
 Yes

11. In the last 12 months, did you need care for
yourself during evenings, weekends, or holidays?
 Yes
 No  If No, Go to Question 13

18. In the last 12 months, when you used e-mail,
MyHealtheVet, or secure messaging to contact this
provider’s office, how often did you receive an answer
to your medical question as soon as you needed?
 Never
 Sometimes
 Usually
 Always
19. In the last 12 months, when you used e-mail,
MyHealtheVet, or secure messaging to contact this
provider’s office, how often were all of the
questions answered?
 Never
 Sometimes
 Usually
 Always
20. Some offices remind patients between visits about
tests, treatment or appointments. In the last 12
months, did you receive any reminders from this
provider’s office between visits?
 Yes
 No
21. Wait time includes time spent in the waiting room
and exam room. In the last 12 months, how often
did you see this provider within 15 minutes of
your appointment time?
 Never
 Sometimes
 Usually
 Always

 No  If No, Go to Question 20

12. In the last 12 months, how often were you able to
receive the care you needed from this provider’s
office during evenings, weekends, or holidays?
 Never
 Sometimes
 Usually
 Always
13. In the last 12 months, did you phone this
provider’s office with a medical question during
regular office hours?
 Yes
 No  If No, Go to Question 15
14. In the last 12 months, when you phoned this
provider’s office during regular office hours, how
often did you receive an answer to your medical
question that same day?
 Never
 Sometimes
 Usually
 Always

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22. In the last 12 months, how often did this provider
explain things in a way that was easy to understand?
 Never
 Sometimes
 Usually
 Always

29. In the last 12 months, did this provider order a
blood test, x-ray, or other test for you?
 Yes
 No  If No, Go to Question 31
30. In the last 12 months, when this provider ordered
a blood test, x-ray, or other test for you, how often
did someone from this provider’s office follow up
to give you those results?
 Never
 Sometimes
 Usually
 Always

23. In the last 12 months, how often did this provider
listen carefully to you?
 Never
 Sometimes
 Usually
 Always

31. In the last 12 months, did you and this provider
talk about starting or stopping a prescription
medicine?
 Yes
 No  If No, Go to Question 35 on Page 6

24. In the last 12 months, did you talk with this
provider about any health questions or concerns?
 Yes
 No  If No, Go to Question 26
25. In the last 12 months, how often did this provider
give you easy to understand information about
these health questions or concerns?
 Never
 Sometimes
 Usually
 Always

32. When you talked about starting or stopping a
prescription medicine, how much did this
provider talk about the reasons you might want to
take a medicine?
 Not at all
 A little
 Some
 A lot

26. In the last 12 months, how often did this provider
seem to know the important information about
your medical history?
 Never
 Sometimes
 Usually
 Always

33. When you talked about starting or stopping a
prescription medicine, how much did this
provider talk about the reasons you might not
want to take a medicine?
 Not at all
 A little
 Some
 A lot

27. In the last 12 months, how often did this provider
show respect for what you had to say?
 Never
 Sometimes
 Usually
 Always

34. When you talked about starting or stopping a
prescription medicine, did this provider ask you
what you thought was best for you?
 Yes
 No

28. In the last 12 months, how often did this provider
spend enough time with you?
 Never
 Sometimes
 Usually
 Always

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

41. In the last 12 months, did you and anyone in this
provider’s office talk at each visit about all the
prescription medicines you were taking?
 Yes
 No
42. In the last 12 months, did anyone in this
provider’s office ask you if there was a period of
time when you felt sad, empty, or depressed?
 Yes
 No
43. In the last 12 months, did you and anyone in this
provider’s office talk about things in your life that
worry you or cause you stress?
 Yes
 No

36. Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and other
doctors who specialize in one area of health care.
In the last 12 months, did you see a specialist for a
particular health problem?
 Yes
 No  If No, Go to Question 38

44. In the last 12 months, did you and anyone in this
provider’s office talk about a personal problem,
family problem, alcohol use, drug use, or a mental
or emotional illness?
 Yes
 No
CLERKS AND RECEPTIONISTS
AT THIS PROVIDER’S OFFICE

37. In the last 12 months, how often did your regular
VA provider seem informed and up-to-date about
the care you received from specialists?
 Never
 Sometimes
 Usually
 Always

45. In the last 12 months, how often were clerks and
receptionists at this provider’s office as helpful as
you thought they should be?
 Never
 Sometimes
 Usually
 Always

PLEASE ANSWER THESE QUESTIONS ABOUT
YOUR REGULAR VA PROVIDER.
38. In the last 12 months, did anyone in this
provider’s office talk with you about specific goals
for your health?
 Yes
 No

46. In the last 12 months, how often did clerks and
receptionists at this provider’s office treat you
with courtesy and respect?
 Never
 Sometimes
 Usually
 Always

39. In the last 12 months, did anyone in this
provider’s office ask you if there are things that
make it hard for you to take care of your health?
 Yes
 No
40. In the last 12 months, did you take any
prescription medicine?
 Yes
 No  If No, Go to Question 42
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ABOUT YOU

52. What language do you mainly speak at home?

English

Spanish

Chinese

Russian

Vietnamese
 Some other language (please print):

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

__________________________________

48. In general, how would you rate your overall
mental or emotional health?
 Excellent
 Very good
 Good
 Fair
 Poor

53. Did someone help you complete this survey?
 Yes
 No
54. How did that person help you? Mark one or more.
 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

49. 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
50. Are you of Hispanic or Latino origin or descent?
 Yes, Hispanic or Latino
 No, not Hispanic or Latino
51. What is your race? Mark one or more.
 White
 Black or African American
 Asian
 Native Hawaiian or Other Pacific Islander
 American Indian or Alaskan Native

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Thank you
Please return the completed survey in the postage-paid envelope.

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.
If you have a specific question about this survey, call 1-866-594-5444.
If you have a specific question about something other than this survey; please refer to the contact options above.
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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