Form VA Form 10-10067 VA Form 10-10067 Access to Care Survey Questionnaire

OMB 2900-XXXX
Estimated Burden: 30 min.

OMB EXP Date: XX/XX/XXXX

VA Dialysis Pilot Questionnaire

THE PAPERWORK REDUCTION ACT OF 1995 requires us to notify you that this information collected is in accordance with the clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average 30 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. Your decision to respond to this survey is voluntary and failure to furnish this information will have no effect on any benefits you are entitled.

What is the purpose for the collection of this information?

The Department of Veterans Affairs is conducting a survey that will help managers and clinicians better understand your perceptions of your access to chronic dialysis care. This evaluation is being executed in cooperation with physicians and their patients.

What will I be asked to do?

We would like for you to complete a survey about your experiences travelling to the dialysis center, the wait time you have experienced, and communication with the dialysis doctor and staff. The survey will take 30 minutes to complete.. The survey will take 30 minutes to complete.

Confidentiality of information?

We will not ask for your name. Any information that you give will be regarded as strictly private. Your answers will be combined with those of other participants in reporting the findings of the assessment. In addition, all information collected from these surveys will be used for the purposes of the program evaluation.

How will participation benefit me?

The information you provide will tell us about the things that make it hard for you to get dialysis care at the dialysis clinic and things that make it easier for you to get dialysis care at the center. This information will help the Veterans Health Administration evaluate the care of veterans at outpatient dialysis clinics.

Do I have to take part?

Participation is entirely voluntary and you can refuse to answer any questions. Refusal to participate will involve no penalty or loss of rights to which individuals are entitled and no penalty or loss of VA or other benefits.

For the below statement, please indicate if you strongly agree, agree, are neutral, disagree, or strongly disagree.

1. The VA dialysis center where I get dialysis is easy to get to.

 Strongly Agree
 Agree

 Neutral

 Disagree

 Strongly Disagree

For the next question, please indicate your best estimate.

2. On average, how long does it take you to travel from home to the dialysis center?

 Less than 15 minutes
 15-30 minutes
 31-45 minutes
 46 to 60 minutes
 1-2 hours
 More than 2 hours

This question asks you about the type of transportation that you used to get to the dialysis clinic.

3. At your last visit, which of the following types of transportation did you use while traveling from home to the dialysis facility?

	Drove alone in a personal vehicle	Yes	No
	Rode with someone else in a personal vehicle	Yes	No
	Public transportation	Yes	No
O	Ambulance H	Yes	No
Han	Handicap accessible van	Yes	No

The next set of questions asks you how well your transportation needs were met by the dialysis center. Select the one response that best represents your experience.

3. Some dialysis centers arrange transportation to the facility for patients. This help can be a shuttle bus or van or tokens or vouchers for a bus or taxi. In the last 3 months, did you ask the center for help arranging permanent transportation?

 Yes

 No- If No, go to question 6

3. How often did VA’s help with arranging transportation get you to and from your dialysis treatment in a timely fashion?

 Never

 Sometimes
 Usually
 Always

6. In the last 3 months, how often were you able to park in a convenient location at the VA dialysis center?

 Never

 Sometimes
 Usually
 Always

The next set of items asks your opinion on the convenience of dialysis services.

7. Overall, how convenient was your dialysis treatment today?

• Very convenient
   Convenient

• Neutral

 Inconvenient

 Very Inconvenient

8. How satisfied are you with the time of day (i.e., morning or afternoon) during which you received your dialysis treatment?

 Very Satisfied
 Satisfied

 Neutral

 Dissatisfied

• Very Dissatisfied

8. If this dialysis center offered evening shifts, would you be interested in receiving treatment in the evenings instead of your current time? (Indicate either “yes” or “no” to this item).

 Yes

 No- If No, go to question 11

10. Please tell us why you are interested in the evenings instead of your current time. Please indicate all that apply to you.

 I work in the daytime.

 I have family commitments during the day.

 It is easier for me to get to the clinic in the evening because someone can drive me there.
 It is easier to get someone to accompany me in the evening.

 I would like the greater flexibility to my day.

11. How satisfied are you with your set of scheduled days for dialysis treatment (i.e., Monday, Wednesday, Friday or Tuesday, Thursday, Saturday)?

 Very Satisfied
 Satisfied

 Neutral

 Dissatisfied

• Very Dissatisfied

The following questions ask you about the extent to which you communicate with your providers
or access information through digital communication technologies (e.g., internet).

12. Have you ever communicated with your VA team or accessed your health care information through the following formats?

1. Telephone

 Yes
 No

2. Home video telehealth

 Yes
 No

3. Email through secure messaging

 Yes
 No

4. MyHealtheVet

 Yes
 No

12. Do you desire more electronic communication with your VA dialysis team?

 Yes
 No

The next few questions ask you several things about yourself so that we can develop a general profile of our

participants.

14. What is your age?

	18-34
	35-44
	45-54
	55-64
	65-74
	75 or over

14. You are

• Male

 Female

16. Are you of Hispanic or Latino origin?

• Yes
   No

16. Which of the following best describes you?

 White
 Black
 Asian/Pacific Islander
 American Indian/Native American
 Other

16. How many years of education have you completed?

 Less than 12 years

• High School Education

• Some College

• College Graduation

• Graduate School/Graduate Degree

16. Are you:

• Married

• Separated

• Divorced

• Widowed

 Never Married

16. Are you employed full-time, part-time, unemployed, or retired?

 Full-Time
 Part-Time

 Unemployed
 Retired

VA Form
MAR 2013

VA Form 10-10067
DATE 2014