VA Form 10-1465-5 SHEP Patient Centered Medical Homes (PCMH) Short Form 10

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

SHEP_PCMH_Short Form 10-1465-5

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⚠️ Notice: This form may be outdated.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:

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ou complete
48. What is your race? Mark one or more.

 White
 Black or African-American
ou. Please return
 Asian
pleted survey in the
 Native Hawaiian or other
-paid envelope.

Pacific Islander
help you? Mark
 American Indian or Alaska Native

50. Did someone help you complete
this survey?




Yes

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

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

SURVEY OF HEALTHCARE

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

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS

51. How did that person help you? Mark
EXPERIENCES OF PATIENTS
one or more.

ons to me 49. What language do you mainly speak
 Read
the questions to me
AMBULATORY
CARE 2013
AMBULATORY CARE 2013
at home?
answers I gave
 Wrote down the answers I gave

English
In order for the VA to carry out its mission to provide the best possible medicalIncare
order
and
for the VA to carry out its mission to provide the best possible medical care and
uestions for me

Answered the questions for me
services
to
all
veterans,
it
is
extremely
important
that
you
complete
and
return
services
this
survey
to all veterans, it is extremely important that you complete and return this survey
 Spanish
uestions into

Translated
the
questions
into
booklet. Your answers will help ensure that all veterans receive the high-quality
booklet.
care they
Your answers will help ensure that all veterans receive the high-quality care they
 Chinese
my language
have earned and so richly deserve.
have earned and so richly deserve.
 Russian
other way
 and
Helped
in some
other
Please read each question
check
the box
thatway
best describes your experience.
Please
Please
readbe
each question and check the box that best describes your experience. Please be
sure to read all pages of this survey booklet.
sure to read all pages of this survey booklet.
 Vietnamese



velope.

The(please
check-box responses you provide to the survey questions will not be connected
The check-box
with you responses you provide to the survey questions will not be connected with you
Some other language
print):
personally but combined with the opinions of other veterans and shared with the
personally
VA facility
but combined with the opinions of other veterans and shared with the VA facility
__________________________
providing your care. However, any additional information which you provide including
providing your care. However, any additional information which you provide including
commentsTHANK
written in
the
margins,
letters,
and
other
enclosures
will
be
shared
with
comments
the Medical
written in the margins, letters, and other enclosures will be shared with the Medical
YOU
Center Director or appropriate staff at your facility if it is the best way to address
Center
your Director or appropriate staff at your facility if it is the best way to address your
Please return the
completed
survey
ininstruct
the postage-paid
concerns,
unless
you
us not to. envelope.
concerns, unless you instruct us not to.

ontact the VA:
If you have a specific question
or need help
your VA
care,
you
may contact
VA: will not affect the healthcare
Participation
is with
voluntary
and
your
answers
to thethe
survey
Participation
you is voluntary and your answers to the survey will not affect the healthcare you
receive or your eligibility for VA benefits.
receive or your eligibility for VA benefits.
1. By telephone:

a. VA Benefits: 1-800-827-1000
If you have a specific question or need help with your VA care, you may contactIf the
youVA
have
as a specific question or need help with your VA care, you may contact the VA as
b. Health Care Benefits:
1-877-222-8387
described
at the end of this survey booklet.
described at the end of this survey booklet.
c. Telecommunications Device for the Deaf (TDD): 1-800-829-4833
Thank you very much!
Thank you very much!
ome page 2.
at Information on a broad range of veterans' benefits is available on our home page at
http://www.va.gov The Paperwork Reduction Act of 1995: This information is collected in accordanceThe
withPaperwork
section
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,
3507
of
the
and
Paperwork
you
Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you
think can help
3. At your local VA medical center, either contact the department that you think can help
are not required to respond to, a collection of information unless it displays a valid OMB
are number.
not required
We to respond to, a collection of information unless it displays a valid OMB number. We
you or ask for the Patient Advocate.
anticipate that the time expended by all individuals who complete this survey will average
anticipate
10 minutes.
that the time expended by all individuals who complete this survey will average 10 minutes.
Thistoincludes
time it VA
will care.
take to
read instructions,
gather the
necessary facts and This
fill out
includes
the form.
the time it will take to read instructions, gather the necessary facts and fill out the form.
or completing
Yourthis
answers are important
help usthe
improve
Thank
you for completing
this
Customer
satisfaction
surveys
are
used
to
gauge
customer
perceptions
of
VA
services
Customer
as
well
as
satisfaction
surveys are used to gauge customer perceptions of VA services as well as
ope we sent
questionnaire.
you.
Please place the completed questionnaire in the envelope we sent you.
customer
and
The results
of thisthe
survey
will to:
lead to improvements
customer
in the quality
expectations and desires. The results of this survey will lead to improvements in the quality
return the No
survey
stamp
to:is required. Simply
placeexpectations
the envelope
in desires.
any mailbox
and return
survey
of service delivery by helping to shape the direction and focus of specific programs and
of service
services.
delivery by helping to shape the direction and focus of specific programs and services.
Department
of
Veterans
Affairs
Disclosure of information involves release of statistical data and other non-identifyingDisclosure
data for theof information involves release of statistical data and other non-identifying data for the
c/oofSynovate
improvement
services within the VA healthcare system and associated administrative
improvement
purposes.of services within the VA healthcare system and associated administrative purposes.
P.O.
806046
Submission
of Box
this form
is voluntary and failure to respond will have no impact on benefits
Submission
to which
of this form is voluntary and failure to respond will have no impact on benefits to whichERROR
Chicago,
IL
60680
you may be entitled.
you may be entitled.
This EPS must b

Version: 43 – 0114
SYN_SHEP_SVY_PCMH_ENG

SYN_SHEP_SVY_PCMH_ENG_<>

an EPS. It can't b
Exported directl
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Version: 43 – 0114

www

SURVEY INSTRUCTIONS
SURVEY INSTRUCTIONS

Answer each question by marking the box to the left of your answer.
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
are see
sometimes
to askip
questions
in this survey.
When
thislike
happens
you
an arrowtold
with
noteover
thatsome
tells you
what question
to answer
next,
this:
you will see an arrow with a note that tells you what question to answer next, like this:
 Yes If Yes, go to #1
 Yes If Yes, go to #1
 No
 No
YOUR CARE FROM THIS PROVIDER

YOURINCARE
FROM12
THIS
PROVIDER
THE LAST
MONTHS
IN THE LAST 12 MONTHS

YOUR PROVIDER
YOUR PROVIDER

1. Our records show that you got care
1. Our
shownamed
that you
got care
fromrecords
the provider
below
in
fromlast
the12
provider
the
months.named below in
the last 12 months.
[CLINICIAN NAME]
<>
[CLINICIAN NAME]
Is that right?
Is that right?

Yes

 Yes
NoIf No, go to #44
 NoIf No, go to #44

These questions ask about your own
These
ask
about care
your you
own
health questions
care. Do not
include
health
care.
Dostayed
not include
careinyou
got
when
you
overnight
a
got
when
you
stayed
overnight
in
hospital. Do not include the times ayou
hospital.
Do notcare
include
the times you
went
for dental
visits.
went for dental care visits.
4. In the last 12 months, how many
4. In
the did
lastyou
12 months,
manyto
times
visit thishow
provider
times
didfor
you
visit this provider to
get
care
yourself?
get care for yourself?
 None If None, go to #44

If None, go to #44
 None
1 time

 12 time

 23

 34

 45 to 9

 510toor9 more times
 10 or more times
5. In the last 12 months, did you
5. In
the last
months, office
did you
phone
this12
provider’s
to get
phone
this provider’s
to injury
get
an
appointment
for anoffice
illness,
an
appointment
for
an
illness,
injury
or condition that needed care right
or condition that needed care right
away?
away?
 Yes

 Yes
NoIf No, go to #8
 NoIf No, go to #8

The questions in this survey will refer
The
questions
this survey
will refer
to
the
provider in
named
in Question
1 as
to
the
provider
named
in
Question
“this provider.” Please think of that1 as
“this provider.”
Pleasethe
think
of that
person
as you answer
survey.
person as you answer the survey.
2.
2.

Is this the provider you usually see
Is
this need
the provider
you usually
if you
a check-up,
want see
if you need
a check-up,
want or
advice
about
a health problem,
advice
a health problem, or
get
sickabout
or hurt?
get sick or hurt?

Yes

 Yes
No
 No
3. How long have you been going to
3. this
Howprovider?
long have you been going to
this provider?
 Less than 6 months

than 6 months
 Less
At least 6 months but less than
 At
least 6 months but less than
1 year
1 year
 At
least 1 year but less than
 At
least 1 year but less than
3 years
3 years
 At
least 3 years but less than
 At
least 3 years but less than
5 years
5 years
 5 years or more
 5 years or more

SYN_SHEP_SVY_PCMH_ENG

ABOUT YOU
ABOUT YOU

40. In the last 12 months, did you and
40. anyone
In the last
12 months,
did office
you and
in this
provider’s
talk
anyone
in
this
provider’s
office
talk
about things in your life that worry
about
your
life that worry
you
orthings
cause in
you
stress?
you or cause you stress?
 Yes

Yes
 No
 No
41. In the last 12 months, did you and
41. In
the last
12 months,
did office
you and
anyone
in this
provider’s
talk
anyonea in
this provider’s
talk
about
personal
problem,office
family
about
a
personal
problem,
family
problem, alcohol use, drug use, or a
problem,
use,illness?
drug use, or a
mental
oralcohol
emotional
mental or emotional illness?
 Yes

Yes
 No
 No

44. In general, how would you rate your
44. In
general,
how would you rate your
overall
health?
overall health?
 Excellent

 Excellent
Very Good

Good
 Very
Good

 Good
Fair

 Fair
Poor
 Poor
45. In general, how would you rate your
45. overall
In general,
howorwould
you rate
your
mental
emotional
health?
overall mental or emotional health?
 Excellent

 Excellent
Very Good

Good
 Very
Good

 Good
Fair

 Fair
Poor
 Poor
46. What is the highest grade or level of
46. school
What isthat
the highest
grade
or level of
you have
completed?
school that you have completed?
 8th grade or less

8th grade or less
 Some
high school, but did not
 Some
high school, but did not
graduate
 graduate
High school graduate or GED

school graduate or GED
 High
Some college or 2-year degree

college or 2-year degree
 Some
4-year college graduate

college graduate
 4-year
More than 4-year college degree
 More than 4-year college degree
47. Are you of Hispanic or Latino origin
47. or
Aredescent?
you of Hispanic or Latino origin
or descent?
 Yes, Hispanic or Latino

Hispanic or Latino
 Yes,
No, Not Hispanic or Latino
 No, Not Hispanic or Latino

CLERKS AND RECEPTIONISTS AT
CLERKS
RECEPTIONISTS
THIS AND
PROVIDER’S
OFFICE AT
THIS PROVIDER’S OFFICE

42. In the last 12 months, how often
42. In
theclerks
last 12and
months,
how often
were
receptionists
at this
were clerksoffice
and receptionists
this
provider’s
as helpful as at
you
provider’s
office
as
helpful
as
you
thought they should be?
thought they should be?
 Never

 Never
Sometimes

 Sometimes
Usually

 Usually
Always
 Always
43. In the last 12 months, how often did
43. clerks
In the last
months, how
and12
receptionists
at often
this did
clerks
and
receptionists
at
this
provider’s office treat you with
provider’sand
office
treat you with
courtesy
respect?
courtesy and respect?
 Never

 Never
Sometimes

 Sometimes
Usually

 Usually
Always
 Always

SYN_SHEP_SVY_PCMH_ENG

32. 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?













Please answer these questions about
the provider named in Question 1 of
the survey.
35. In the last 12 months, did anyone in
this provider’s office talk with you
about specific goals for your
health?

Worst provider possible




2
3
4
5
6
7




8
9
10 Best provider possible




Yes
No If No, go to #39

38. 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 If No, go to #35

Yes
No

39. 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?

Never




Sometimes
Usually
Always

SYN_SHEP_SVY_PCMH_ENG

Yes

37. In the last 12 months, did you take
any prescription medicine?

34. In the last 12 months, how often did
the provider named in Question 1
seem informed and up-to-date
about the care you got from
specialists?






36. 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?

33. 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

Yes
No

6. In the last 12 months, when you
phoned this provider’s office to get
an appointment for care you needed
right away, how often did you get
an appointment as soon as you
needed?






10. Did this provider’s office give you
information about what to do if you
needed care during evenings,
weekends, or holidays?




Never
Usually
Always




Same day
1 day






2 to 3 days
4 to 7 days
More than 7 days

No If No, go to #13

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 #10




9. In the last 12 months, when you
made an appointment for a checkup or routine care with this
provider, how often did you get an
appointment as soon as you
needed?






Yes

12. In the last 12 months, how often
were you able to get the care you
needed from this provider’s office
during evenings, weekends, or
holidays?

8. In the last 12 months, did you make
any appointments for a check-up or
routine care with this provider?




11. In the last 12 months, did you need
care for yourself during evenings,
weekends, or holidays?

Sometimes

7. In the last 12 months, how many
days did you usually have to wait
for an appointment when you
needed care right away?







Yes

Yes
No If No, go to #15

14. In the last 12 months, when you
phoned this provider’s office during
regular office hours, how often did
you get an answer to your medical
question that same day?

Never






Sometimes
Usually
Always

Never
Sometimes
Usually
Always

SYN_SHEP_SVY_PCMH_ENG

15. In the last 12 months, did you
phone this provider’s office with a
medical question after regular office
hours?




19. In the last 12 months, how often did
this provider explain things in a way
that was easy to understand?






Yes
No If No, go to #17

16. In the last 12 months, when you
phoned this provider’s office after
regular office hours, how often did
you get an answer to your medical
question as soon as you needed?






Never
Sometimes
Usually
Always




Always

Never
Sometimes
Usually
Always

Yes
No If No, go to #23

22. In the last 12 months, how often did
this provider give you easy to
understand information about these
health questions or concerns?

Yes
No






Never

Never
Sometimes
Usually
Always

23. In the last 12 months, how often did
this provider seem to know the
important information about your
medical history?

Sometimes
Usually
Always

SYN_SHEP_SVY_PCMH_ENG

Usually

21. In the last 12 months, did you talk
with this provider about any health
questions or concerns?

18. 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?






Sometimes

20. In the last 12 months, how often did
this provider listen carefully to you?

17. Some offices remind patients
between visits about tests,
treatment or appointments. In the
last 12 months, did you get any
reminders from this provider’s
office between visits?




Never






24. In the last 12 months, how often did
this provider show respect for what
you had to say?






28. In the last 12 months, did you and
this provider talk about starting or
stopping a prescription medicine?




Never
Sometimes
Usually






Never
Sometimes
Usually
Always

Yes






No If No, go to #28

27. 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?






Not at all
A little
Some
A lot

30. 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?

26. In the last 12 months, did this
provider order a blood test, x-ray, or
other test for you?




No If No, go to #32

29. 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?

Always

25. In the last 12 months, how often did
this provider spend enough time
with you?






Yes

Not at all
A little
Some
A lot

31. When you talked about starting or
stopping a prescription medicine,
did this provider ask you what you
thought was best for you?

Never
Sometimes




Usually
Always

Yes
No

Never
Sometimes
Usually
Always

SYN_SHEP_SVY_PCMH_ENG

15. In the last 12 months, did you
phone this provider’s office with a
medical question after regular office
hours?




19. In the last 12 months, how often did
this provider explain things in a way
that was easy to understand?






Yes
No If No, go to #17

16. In the last 12 months, when you
phoned this provider’s office after
regular office hours, how often did
you get an answer to your medical
question as soon as you needed?






Never
Sometimes
Usually
Always




Always

Never
Sometimes
Usually
Always

Yes
No If No, go to #23

22. In the last 12 months, how often did
this provider give you easy to
understand information about these
health questions or concerns?

Yes
No






Never

Never
Sometimes
Usually
Always

23. In the last 12 months, how often did
this provider seem to know the
important information about your
medical history?

Sometimes
Usually
Always

SYN_SHEP_SVY_PCMH_ENG

Usually

21. In the last 12 months, did you talk
with this provider about any health
questions or concerns?

18. 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?






Sometimes

20. In the last 12 months, how often did
this provider listen carefully to you?

17. Some offices remind patients
between visits about tests,
treatment or appointments. In the
last 12 months, did you get any
reminders from this provider’s
office between visits?




Never






24. In the last 12 months, how often did
this provider show respect for what
you had to say?






28. In the last 12 months, did you and
this provider talk about starting or
stopping a prescription medicine?




Never
Sometimes
Usually






Never
Sometimes
Usually
Always

Yes






No If No, go to #28

27. 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?






Not at all
A little
Some
A lot

30. 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?

26. In the last 12 months, did this
provider order a blood test, x-ray, or
other test for you?




No If No, go to #32

29. 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?

Always

25. In the last 12 months, how often did
this provider spend enough time
with you?






Yes

Not at all
A little
Some
A lot

31. When you talked about starting or
stopping a prescription medicine,
did this provider ask you what you
thought was best for you?

Never
Sometimes




Usually
Always

Yes
No

Never
Sometimes
Usually
Always

SYN_SHEP_SVY_PCMH_ENG

32. 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?













Worst provider possible




2
3
4
5
6
7




8
9
10 Best provider possible




Yes
No If No, go to #39

38. 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 If No, go to #35

Yes
No

39. 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?

Never




Sometimes
Usually
Always

SYN_SHEP_SVY_PCMH_ENG

Yes

37. In the last 12 months, did you take
any prescription medicine?

34. In the last 12 months, how often did
the provider named in Question 1
seem informed and up-to-date
about the care you got from
specialists?






36. 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

Yes
No

6. In the last 12 months, when you
phoned this provider’s office to get
an appointment for care you needed
right away, how often did you get
an appointment as soon as you
needed?






10. Did this provider’s office give you
information about what to do if you
needed care during evenings,
weekends, or holidays?




Never
Usually
Always




Same day
1 day






2 to 3 days
4 to 7 days
More than 7 days

No If No, go to #13

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 #10




9. In the last 12 months, when you
made an appointment for a checkup or routine care with this
provider, how often did you get an
appointment as soon as you
needed?






Yes

12. In the last 12 months, how often
were you able to get the care you
needed from this provider’s office
during evenings, weekends, or
holidays?

8. In the last 12 months, did you make
any appointments for a check-up or
routine care with this provider?




11. In the last 12 months, did you need
care for yourself during evenings,
weekends, or holidays?

Sometimes

7. In the last 12 months, how many
days did you usually have to wait
for an appointment when you
needed care right away?







Yes

Yes
No If No, go to #15

14. In the last 12 months, when you
phoned this provider’s office during
regular office hours, how often did
you get an answer to your medical
question that same day?

Never






Sometimes
Usually
Always

Never
Sometimes
Usually
Always

SYN_SHEP_SVY_PCMH_ENG

SURVEY INSTRUCTIONS
SURVEY INSTRUCTIONS

YOURINCARE
FROM12
THIS
PROVIDER
THE LAST
MONTHS
IN THE LAST 12 MONTHS

YOUR PROVIDER
YOUR PROVIDER

SYN_SHEP_SVY_PCMH_ENG

ABOUT YOU
ABOUT YOU

CLERKS AND RECEPTIONISTS AT
CLERKS
RECEPTIONISTS
THIS AND
PROVIDER’S
OFFICE AT
THIS PROVIDER’S OFFICE

SYN_SHEP_SVY_PCMH_ENG

ou complete
48. What is your race? Mark one or more.

 White
 Black or African-American
ou. Please return
 Asian
pleted survey in the
 Native Hawaiian or other
-paid envelope.

Pacific Islander
help you? Mark
 American Indian or Alaska Native

50. Did someone help you complete
this survey?




Yes

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

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

SURVEY OF HEALTHCARE

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

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS

51. How did that person help you? Mark
EXPERIENCES OF PATIENTS
one or more.



velope.

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SYN_SHEP_SVY_PCMH_ENG

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