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

Nation-wide Customer Satisfaction Surveys (Survey of Healthcare Experiences of Patients (SHEP)

SHEP_OutPatient_Long Form 10-1465-3

Nation-wide Customer Satisfaction Surveys

OMB: 2900-0712

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2900-0712 can be found here:

Document [pdf]

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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
SURVEY OF HEALTHCARE
http:// www.va.gov
3. At your local VA medical center. Either contact the department thatEXPERIENCES
you think can help
OF PATIENTS
you or ask for the Patient Advocate.

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

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS

uestionnaire.
YourPlease
answers are important to help us improve VA care. Thank youAMBULATORY
for completing this questionnaire.
CAREPlease
2013
AMBULATORY CARE 2013
ly place place
the envelope
the completed
in
questionnaire in the envelope we sent you. No stamp is required. Simply place the envelope in
In order
order
veterans,
for the
it VA to carry out its mission to provide the best possible medical care and services to all veterans, it
any mailbox and return the survey
to: for the VA to carry out its mission to provide the best possible medical care and services toInall
is extremely important that you complete and return this survey booklet. Your answers will help ensure
is extremely
that allimportant 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.
veterans receive the high-quality care they have earned and so richly deserve.
Department of Veterans Affairs
Please read each question
and check the box that best describes your experience. Please be sure to read
Please
allread
pages
each
of question and check the box that best describes your experience. Please be sure to read all pages of
c/o Synovate
this survey booklet.
this survey booklet.
P.O. Box 806046
Chicago, IL 60680
The check-box responses you provide to the survey questions will not be connected with you personally
The check-box
but
responses you provide to the survey questions will not be connected with you personally but
combined with the opinions of other veterans and shared with the VA facility providing your care. combined
However,with
any the opinions of other veterans and shared with the VA facility providing your care. However, any
additional information which you provide including comments written in the margins, letters, and additional
other enclosures
information which you provide including comments written in the margins, letters, and other enclosures
will be shared with the Medical Center Director or appropriate staff at your facility if it is the best will
waybe
to shared
addresswith the Medical Center Director or appropriate staff at your facility if it is the best way to address
your concerns, unless you instruct us not to.
your concerns, unless you instruct us not to.
Participation is voluntary and your answers to the survey will not affect the healthcare you receiveParticipation
or your
is voluntary and your answers to the survey will not affect the healthcare you receive or your
eligibility for VA benefits.
eligibility for VA benefits.
If you have a specific question or need help with your VA care, you may contact the VA as described
If you
at the
have
enda of
specific question or need help with your VA care, you may contact the VA as described at the end of
this survey booklet.
this survey booklet.
Thank you very much!

Thank you very much!

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507The
of the
Paperwork
PaperworkReduction 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
Reduction
to, a collection
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
of information
who
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
complete
the necessary
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 facts
services
andasfillwell
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
as service
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
delivery by
involves
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
release ofsystem
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 and
haveassociated
no impactadministrative purposes. Submission of this form is voluntary and failure to respond will have no impact
on benefits to which you may be entitled.
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
Ourto
records
this show that you recently visited the VA facility described below. You will be asked to refer to this
information later in the survey:
information later in the survey:

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65. How much of the time during the past 4 weeks:
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

Please think about all of the healthcare you received from
the VA in the last 12 months.

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?



Never
Sometimes
Usually
Always

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  If No, Go to Question 3

In the last 12 months, when you needed care right
away, how often did you get care as soon as you
thought you needed?





Yes
No  If No, Go to Question 5

Never
Sometimes
Usually
Always

None
1
2
3
4
5 to 9
10 or more

None of
the time



Did you have a lot of energy?



Have you felt downhearted
and blue?



69. What is the highest grade or level of school that

has your physical health or emotional problems
interfered with your social activities (like visiting
with friends, relatives, etc.)?






you have completed?








All of the time
Most of the time
Some of the time
A little of the time
None of the time




Yes
No

Yes, Hispanic or Latino
No, Not Hispanic or Latino

71. What is your race? Please choose one or more.






68. If you have been treated by a VA provider for

chronic pain, please rate the effectiveness of your
pain treatment?







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

70. Are you of Hispanic or Latino origin or descent?

Poor
Fair
Good
Very good
Excellent

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

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

Yes
No  If No, Go to Question 10

2
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

A little of
the time



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?



Some of
the time

Have you felt calm and
peaceful?

chronic pain in the past 12 months?

Never
Sometimes
Usually
Always

A good bit
of the time

67. Have you been treated by a VA provider for

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?





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?





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?








Most of
the time

66. How much of the time during the past 4 weeks

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

All of
the time

11
11

SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

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

one occasion in the past 12 months?







Never
Less than monthly
Monthly
Weekly
Daily or almost daily







Yes
No

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?




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





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

interfere with your normal work (including
both work outside the home and
housework)?

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







Accomplished less than you would like?






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

64. During the past 4 weeks, how much did pain

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

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






Definitely Yes
Somewhat Yes
Somewhat No
Definitely No

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?

Definitely Yes
Somewhat Yes
Somewhat No
Definitely No




Not at all
A little bit
Moderately
Quite a bit
Extremely

visit your personal VA doctor or nurse to get care
for yourself?








0
Worst healthcare possible
1
2
3
4
5
6
7
8
9
10 Best healthcare possible

VA doctor or nurse explain things in a way that
was easy to understand?






tests or treatment through VA?

Never
Sometimes
Usually
Always

16. In the last 12 months, how often did your personal

Yes
No  If No, Go to Question 13

VA doctor or nurse listen carefully to you?






10
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

None  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

11. In the past 12 months, did you try to get any care,



Yes
No  If No, Go to Question 21

14. In the last 12 months, how many times did you

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?













Never
Sometimes
Usually
Always
YOUR PERSONAL VA
DOCTOR OR NURSE

10. Using any number from 0 to 10, where 0 is the

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

Climbing several flights of stairs?

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

the care, tests or treatment you thought you
needed through VA?

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?





Accomplished less than you would like






61. The following two questions are about

12. In the past 12 months, how often was it easy to get

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?





the following problems with your work or
other regular daily activities as a result of
any emotional problems (such as feeling
depressed or anxious)?

other VA health care provider advised you
about your drinking (to drink less or not to
drink alcohol)?

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, have you had any of

60. In the past 12 months has a VA doctor or




Were limited in the kind of work or other
activities?

Never
Sometimes
Usually
Always

3
3

SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

GETTING HEALTH CARE FROM VA
SPECIALISTS

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?






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?

Never
Sometimes
Usually
Always




VA doctor or nurse show respect for what you had
to say?













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?

Never
Sometimes
Usually
Always

None  If None, Go to Question 25
1 VA specialist
2
3
4
5 or more VA specialists






following conditions? Check all that apply.





any of the following conditions? Check all
that apply.

Never
Sometimes
Usually
Always






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
Sometimes
Usually
Always








Yes
No
Don’t know

have on a typical day when you were
drinking in the past 12 months?


medication that makes taking aspirin unsafe
for you?







Yes
No
Don’t know

4
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

Never  If Never, Go to Question 61
Monthly or less
2-4 times a month
2-3 times a week
4-5 times a week
6 or more times a week

58. How many drinks containing alcohol did you

53. Do you have a health problem or take




A heart attack
Angina or coronary heart disease
A stroke
Any kind of diabetes or high blood sugar

57. How often did you have a drink containing

day?





High cholesterol
High blood pressure
Parent or sibling with heart attack before
the age of 60

56. Has a VA doctor ever told you that you have

52. Do you take aspirin daily or every other

0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible

Yes
No

55. Are you aware that you have any of the

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.

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?















51. In the last 12 months, how often did your VA

24. We want to know your rating of the VA specialist

0 Worst personal doctor/nurse possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor/nurse possible

Never
Sometimes
Usually
Always

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.

12 months?

Never
Sometimes
Usually
Always

discussed with you the risks and benefits of
aspirin to prevent heart attack or stroke?

50. In the last 12 months, how often was

23. How many VA specialists have you seen in the last

VA doctor or nurse spend enough time with you?













Yes
No  If No, Go to Question 25

appointments with VA specialists?

19. In the last 12 months, how often did your personal










22. In the last 12 months, how often was it easy to get

Never
Sometimes
Usually
Always

54. Has a VA doctor or VA health provider ever

advised to quit smoking or using tobacco by a
VA doctor or other VA health provider?

21. Specialists are doctors like surgeons, heart

18. In the last 12 months, how often did your personal





49. In the last 12 months, how often were you

0 drinks (Did not drink in the past 12
months)  If 0, Go to Question 61
1-2 drinks
3-4 drinks
5-6 drinks
7-9 drinks
10 or more drinks

9
9

SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

40. If you had a complaint, how easy was it for
you
to had
findasomeone
to hear
complaint?
40.
you
complaint,
how your
easy was
it for
40. If
If
you
had
a
complaint,
how
easy
was it for
Very
easy
 to
you
find
someone
to
hear
your
complaint?
40.
40. IfIf
you
you
had
complaint,
complaint,
howeasy
easywas
was
ititfor
for
you
tohad
findaasomeone
to how
hear
your
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
Easy
Very
easy

you
you
to
to
find
find
someone
someone
to
to
hear
hear
your
your
complaint?
complaint?
40. IfyouVery
had easy
a complaint, how easy was it for

45. If you did not get a flu vaccine in September
2013
later,
Mark the
MAIN
45.
If youordid
not why
get anot?
flu vaccine
in September
45. reason:
If you did not get a flu vaccine in September
ordid
later,
Mark
the
MAIN
45.
45. 2013
IfIf
you
you
not
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fluvaccine
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Mark to
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I
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the flu

reason:
2013
2013
or
or
later,
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why
why
not?
not?
Mark
Mark
the
the
MAIN
MAIN
reason:
45. If you
did not
getyear
a flu
vaccine
vaccine
this
because
ofin
theSeptember
shortage

Difficult


Easy
Very
Very
easy
 to
you
findeasy
someone to hear your complaint?

Easy

Very
difficult
Difficult


Easy
Very
easy

Difficult
 Easy

Not
applicable

Very
difficult
Difficult


Easy
 Difficult
Very difficult
Not
applicable
Very
Very
difficult
difficult
Difficult

41. 
If
spoke
with someone at the VA location
you
Not
applicable


Not
Not
applicable
applicable
about
a
complaint,
how satisfied
you
Very
difficult
41.
If you spoke with someone
at the were
VA location
41. 
If you
spoke
with
someone
at
the
VA
location
with
the
way
your
complaint
was
handled?
Notcomplaint,
applicable how satisfied were you
41.
41. about
IfIf
you
youaspoke
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someone
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theVA
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aspoke
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how satisfied
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you
Very
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
with
the
way
your
complaint
was
handled?
about
about
a
a
complaint,
complaint,
how
how
satisfied
satisfied
were
were
you
you
with
the
way
your
complaint
was
handled?
41. 
If you
spoke with someone at the VA location
Satisfied
Very
satisfied

with
with
the
the
way
way
your
your
complaint
complaint
was
was
handled?
handled?
about
a complaint,
satisfied how satisfied were you
 Very

Dissatisfied
Satisfied
Very
Very
satisfied
satisfied


with
the
way
your complaint was handled?
 Satisfied

Very
dissatisfied

Dissatisfied

Satisfied
Very
satisfied

 Satisfied
Dissatisfied

Not
applicable

Very
dissatisfied

Dissatisfied

Satisfied
 Dissatisfied
Very dissatisfied
applicable
 Not
Very
Very
dissatisfied
dissatisfied

Dissatisfied
42. 
How
long
did
it take for the VA location to

Not applicable

 Not
Not
applicable
applicable
resolve
your
complaint?
Very
dissatisfied
42.
How long did it take for the VA location to
42. 
HowSame
long
did it take for the VA location to
Not
applicable
day
your
complaint?
42.
42. resolve
How
How
long
long
did
did
itittake
takefor
forthe
theVA
VAlocation
locationtoto
resolve
your
complaint?

2–7
days
Same
daycomplaint?

resolve
your
your
complaint?
42. resolve
How
Samedid
dayit take for the VA location to
 long

8–14
days

2–7
days
Same
day
day
 Same
resolve
your
complaint?

2–7
days
15–21
days


8–14
days

2–7
2–7
days
days
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88

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
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comfort
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phone
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

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
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when
when
you
you
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have
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your
medication
provider
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you
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f.
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VA
pharmacy
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

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
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
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27.questions
Overall,when
how
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provider
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28. During the past 3 months, did you receive

 medications
or supplies from

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services provided
at medication
the
[FACILITY
NAME]
questions
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27.
how satisfied
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you with pharmacy
28.
During the past
3 months, didthe
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27. Overall,
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provided
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[FACILITY
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withpharmacy
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how
satisfied
were
you
with
pharmacy
28.
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During
During
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thepast
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3supplies
3months,
months,
did
didthe
you
you
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receive
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[FACILITY
NAME]
three
months?
medications
or
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VA
pharmacy in
pharmacy
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past
Yes

the
mail?
services
provided
provided
atatthe
the
[FACILITY
[FACILITY
NAME]
NAME]
services
provided
<>
medications
medications
or
or
supplies
supplies
from
from
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the
VA
VA
pharmacy
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pharmacy
outpatient
window
during
the
past
the
mail?
27. services
Overall,
how
satisfied
were
you
with
pharmacy
28. During the past 3 months, did you receive
satisfied
 Very
three
months?

No
 If No, Go to Question 31
pharmacy
pharmacy
outpatient
outpatient
window
window
during
duringNAME]
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thepast
past
Yes
the
the
mail?
mail?
three months?
pharmacy
outpatient
window
during
the
past
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at the
[FACILITY
medications
 Yes or supplies from the VA pharmacy in

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Very
satisfied

three
three
months?
months?
three
months?
pharmacy
outpatient window during the past

No
Yes  If No, Go to Question 31
 Yes
satisfied
 Very
the
 mail?
No  If No, Go to Question 31

Neither
satisfied nor dissatisfied

Satisfied
Very
Very
satisfied
satisfied

three
months?
 Satisfied

 Yes
No
No 
IfIfNo,
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GototoQuestion
Question31
31

Dissatisfied

Neither
satisfied nor dissatisfied

Satisfied
Satisfied
Very
satisfied

 Neither satisfied nor dissatisfied
 No  If No, Go to Question 31
Very
dissatisfied

Dissatisfied


Neither
Neither
satisfied
satisfied
nor
nor
dissatisfied
dissatisfied
Satisfied
 Dissatisfied
Very
dissatisfied


Dissatisfied
Neither
satisfied nor dissatisfied
Very dissatisfied
 Dissatisfied
Very
dissatisfied
dissatisfied

 Very
Dissatisfied
 Very dissatisfied

5
5

5
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG
5
55

29. Please tell us about the medications or supplies you received from the VA pharmacy in the mail. How often did

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

these things happen to you?

Never

Sometimes

Usually

Always




34. How would you rate the following aspects of the examination or treatment room:










a. I received the wrong medication or supplies
b. The medication or supplies were for another person
c. The amount of medication or supplies received was too
small
d. The amount of medication or supplies received was too
large
e. The package had no medication or supplies
f.

The package was damaged

g. The medication in the package was too hot
h. The medication in the package was too cold
i. There was an unexplained change to the medication or
supplies I received



wait in line to check in?

pharmacy services provided through the mail
during the past 3 months?








Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

No wait
1 to 10 minutes
11 to 20 minutes
21 to 30 minutes
31 to 60 minutes
More than 1 hour

Good

Very
Good

Excellent

Does Not
Apply

Cleanliness of the room



Privacy while in the room



Noise level



Sense of safety and security



Poor

Fair

Good

Very
Good

Excellent

Does Not
Apply

Cleanliness of the
reception/waiting area



Cleanliness of the restroom/lavatory



Availability of parking



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?



33. How long after the time when your appointment

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.

was scheduled to begin did you wait to be seen?








31. What was the reason for your recent visit? (You
may choose more than one.)









Fair

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

32. On the day of your appointment, how long did you

30. Overall, how satisfied were you with VA








Poor

Routine physical
Routine follow-up
Flare-up of a long-term problem
Get help with a new problem
Prescription refill
Other

No wait
1 to 10 minutes
11 to 20 minutes
21 to 30 minutes
31 to 60 minutes
More than 1 hour

38. If you reported this complaint to someone at

36. All things considered, how satisfied were you

the VA location where you received your
care, to whom did you report this complaint?

with the VA during your recent visit?









Completely satisfied
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
Completely dissatisfied






39. If you did not report this complaint, what

was the most important reason you did not
report it? (Please mark only one.)

ABOUT COMMUNICATING WITH VA




37. Did you have a complaint about how you
were treated (medically or personally)
during your recent healthcare visit?





Yes
No  If No, Go to Question 43




6
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

Treatment team  Go to Question 40
Patient advocate  Go to Question 40
Other VA staff  Go to Question 40
Did not report the complaint to a VA
employee

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
7
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

29. Please tell us about the medications or supplies you received from the VA pharmacy in the mail. How often did

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

these things happen to you?

Never

Sometimes

Usually

Always




34. How would you rate the following aspects of the examination or treatment room:










The package was damaged

g. The medication in the package was too hot
h. The medication in the package was too cold
i. There was an unexplained change to the medication or
supplies I received



wait in line to check in?

pharmacy services provided through the mail
during the past 3 months?








Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

No wait
1 to 10 minutes
11 to 20 minutes
21 to 30 minutes
31 to 60 minutes
More than 1 hour

Good

Very
Good

Excellent

Does Not
Apply

Cleanliness of the room



Privacy while in the room



Noise level



Sense of safety and security



Poor

Fair

Good

Very
Good

Excellent

Does Not
Apply

Cleanliness of the
reception/waiting area



Cleanliness of the restroom/lavatory



Availability of parking



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?



33. How long after the time when your appointment

was scheduled to begin did you wait to be seen?








31. What was the reason for your recent visit? (You
may choose more than one.)









Fair

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

32. On the day of your appointment, how long did you

30. Overall, how satisfied were you with VA








Poor

Routine physical
Routine follow-up
Flare-up of a long-term problem
Get help with a new problem
Prescription refill
Other

No wait
1 to 10 minutes
11 to 20 minutes
21 to 30 minutes
31 to 60 minutes
More than 1 hour

38. If you reported this complaint to someone at

36. All things considered, how satisfied were you

the VA location where you received your
care, to whom did you report this complaint?

with the VA during your recent visit?









Completely satisfied
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
Completely dissatisfied






39. If you did not report this complaint, what

was the most important reason you did not
report it? (Please mark only one.)

ABOUT COMMUNICATING WITH VA




37. Did you have a complaint about how you
were treated (medically or personally)
during your recent healthcare visit?





Yes
No  If No, Go to Question 43




6
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

Treatment team  Go to Question 40
Patient advocate  Go to Question 40
Other VA staff  Go to Question 40
Did not report the complaint to a VA
employee

SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

5
5

5
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG
5
55

GETTING HEALTH CARE FROM VA
SPECIALISTS

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?






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?

Never
Sometimes
Usually
Always




VA doctor or nurse show respect for what you had
to say?













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?

Never
Sometimes
Usually
Always

None  If None, Go to Question 25
1 VA specialist
2
3
4
5 or more VA specialists






following conditions? Check all that apply.





any of the following conditions? Check all
that apply.

Never
Sometimes
Usually
Always






Never
Sometimes
Usually
Always








Yes
No
Don’t know

have on a typical day when you were
drinking in the past 12 months?


medication that makes taking aspirin unsafe
for you?







Yes
No
Don’t know

4
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

Never  If Never, Go to Question 61
Monthly or less
2-4 times a month
2-3 times a week
4-5 times a week
6 or more times a week

58. How many drinks containing alcohol did you

53. Do you have a health problem or take




A heart attack
Angina or coronary heart disease
A stroke
Any kind of diabetes or high blood sugar

57. How often did you have a drink containing

day?





High cholesterol
High blood pressure
Parent or sibling with heart attack before
the age of 60

56. Has a VA doctor ever told you that you have

52. Do you take aspirin daily or every other

0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible

Yes
No

55. Are you aware that you have any of the




51. In the last 12 months, how often did your VA

24. We want to know your rating of the VA specialist

0 Worst personal doctor/nurse possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor/nurse possible

Never
Sometimes
Usually
Always

12 months?

Never
Sometimes
Usually
Always

discussed with you the risks and benefits of
aspirin to prevent heart attack or stroke?

50. In the last 12 months, how often was

23. How many VA specialists have you seen in the last

VA doctor or nurse spend enough time with you?













Yes
No  If No, Go to Question 25

appointments with VA specialists?

19. In the last 12 months, how often did your personal










22. In the last 12 months, how often was it easy to get

Never
Sometimes
Usually
Always

54. Has a VA doctor or VA health provider ever

advised to quit smoking or using tobacco by a
VA doctor or other VA health provider?

21. Specialists are doctors like surgeons, heart

18. In the last 12 months, how often did your personal





49. In the last 12 months, how often were you

0 drinks (Did not drink in the past 12
months)  If 0, Go to Question 61
1-2 drinks
3-4 drinks
5-6 drinks
7-9 drinks
10 or more drinks

9
9

SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

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

one occasion in the past 12 months?







Never
Less than monthly
Monthly
Weekly
Daily or almost daily







Yes
No

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?




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





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

interfere with your normal work (including
both work outside the home and
housework)?

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







Accomplished less than you would like?






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

64. During the past 4 weeks, how much did pain

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

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






Definitely Yes
Somewhat Yes
Somewhat No
Definitely No

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?

Definitely Yes
Somewhat Yes
Somewhat No
Definitely No




Not at all
A little bit
Moderately
Quite a bit
Extremely

visit your personal VA doctor or nurse to get care
for yourself?








0
Worst healthcare possible
1
2
3
4
5
6
7
8
9
10 Best healthcare possible

VA doctor or nurse explain things in a way that
was easy to understand?






tests or treatment through VA?

Never
Sometimes
Usually
Always

16. In the last 12 months, how often did your personal

Yes
No  If No, Go to Question 13

VA doctor or nurse listen carefully to you?






10
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

None  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

11. In the past 12 months, did you try to get any care,



Yes
No  If No, Go to Question 21

14. In the last 12 months, how many times did you

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?













Never
Sometimes
Usually
Always
YOUR PERSONAL VA
DOCTOR OR NURSE

10. Using any number from 0 to 10, where 0 is the

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

Climbing several flights of stairs?

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

the care, tests or treatment you thought you
needed through VA?

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?





Accomplished less than you would like






61. The following two questions are about

12. In the past 12 months, how often was it easy to get

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?





the following problems with your work or
other regular daily activities as a result of
any emotional problems (such as feeling
depressed or anxious)?

other VA health care provider advised you
about your drinking (to drink less or not to
drink alcohol)?

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, have you had any of

60. In the past 12 months has a VA doctor or




Were limited in the kind of work or other
activities?

Never
Sometimes
Usually
Always

3
3

SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

Please think about all of the healthcare you received from
the VA in the last 12 months.

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?



Never
Sometimes
Usually
Always

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  If No, Go to Question 3

In the last 12 months, when you needed care right
away, how often did you get care as soon as you
thought you needed?





Yes
No  If No, Go to Question 5

Never
Sometimes
Usually
Always

None
1
2
3
4
5 to 9
10 or more

None of
the time



Did you have a lot of energy?



Have you felt downhearted
and blue?



69. What is the highest grade or level of school that

has your physical health or emotional problems
interfered with your social activities (like visiting
with friends, relatives, etc.)?






you have completed?








All of the time
Most of the time
Some of the time
A little of the time
None of the time




Yes
No

Yes, Hispanic or Latino
No, Not Hispanic or Latino

71. What is your race? Please choose one or more.






68. If you have been treated by a VA provider for

chronic pain, please rate the effectiveness of your
pain treatment?







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

70. Are you of Hispanic or Latino origin or descent?

Poor
Fair
Good
Very good
Excellent

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

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

Yes
No  If No, Go to Question 10

2
SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

A little of
the time



Some of
the time

Have you felt calm and
peaceful?

chronic pain in the past 12 months?

Never
Sometimes
Usually
Always

A good bit
of the time

67. Have you been treated by a VA provider for

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?





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?








Most of
the time

66. How much of the time during the past 4 weeks

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

All of
the time

11
11

SYN_SHEP_SVY_PHARM_OP_LONG_FLU_ENG

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

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS

Thank you very much!

*** YOUR RECENT VISIT TO A VA FACILITY ***

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File Created	2013-11-07