Veterans Experience Appointment Schedule Survey (Rev)

OMB: 2900-0770
Expiration: 08/31/2017
Respondent Burden: 1 minute
We are asking for this information so that you can provide compliments, comments, or concerns to VA. Title 38, United States Code, allows us to ask
for this information. We estimate that you will need an average of 1 minute to review the instructions and complete this form. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this
number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you
can call 1-844-MyVA311 (1-844-698-2311) to get information on where to send comments or suggestions about this form.

VA Outpatient Survey Question Review
Strongly Disagree

1
O

2
O

3
O

4
O

5
O

Strongly Agree

Rating Scale (should also include N/A as an option)

Appointment Survey 1.0
Rating Scale Questions
1.

I got my appointment on a date and time that worked for me. *

2.

When scheduling my appointment, I was treated with courtesy and respect.

3.

I trust for my health care needs. *

Open Text Question
Thank you, . What went well? What went wrong? Please share any additional
feedback about making your appointment at . Note, please
do NOT include any personally identifiable information, Social Security Number, Veteran
ID, or medical information, but do provide details about your experience.

Follow-up Question
Would you like a patient advocate to follow up with you about your scheduling experience
for ?
(Respondent has the option to check yes, is then prompted to provide email or phone #)
VA Outpatient Survey Questions FINAL | 1
3/16/2017

Healthcare Survey 1.1
Rating Scale Questions
1.

After I entered I found it easy getting to my appointment.

2.

After I checked in for my appointment, I was told what to expect.

3.

My provider listened carefully to me. *

4.

My provider explained things in a way that I could understand.

5.

After my visit, I knew what I needed to do next.

6.

I trust for my health care needs. *

Open Text Question
Thank you, . What went well? What went wrong? Please share any additional
feedback about making your appointment at . Note, please do
NOT include any personally identifiable information, Social Security Number, Veteran ID,
or medical information, but do provide details about your experience.

Follow-up Question
Would you like a patient advocate to follow up with you about your visit at
?
(Respondent has the option to check yes, is then prompted to provide email or phone #)

VA Outpatient Survey Questions FINAL | 2
3/16/2017

Pharmacy Survey1.2
Rating Scale Questions
1. I found it easy to get my prescriptions at Pharmacy *
[Survey NEVER shows 1 AND 2 at the same time, as the data determine whether question 1 or
question 2 is displayed]
2. I found it easy to get my prescriptions by mail. *
3. When I picked up my prescription/s, I was treated with courtesy and respect. *
4. I trust for my health care needs. *

Open Text Question
Thank you, . What went well? What went wrong? Please share any additional
feedback about making your appointment at . Note, please Do
NOT include any personally identifiable information, Social Security Number, Veteran ID,
or medical information, but do provide details about your experience.

Follow-up Question
Would you like a patient advocate to follow up with you about your and/or
experience at ?
(Respondent has the option to check yes, is then prompted to provide email or phone #)

VA Outpatient Survey Questions FINAL | 3
3/16/2017

Labs/Imaging Survey 1.3
Rating Scale Questions
1. When I got my tests done (blood draw, x-ray, MRI, CT scan, etc.), I was treated with
courtesy and respect. *
2. I trust for my health care needs. *

Open Text Question
Thank you, . What went well? What went wrong? Please share any additional
feedback about making your appointment at . Note, please
Do NOT include any personally identifiable information, Social Security Number, Veteran
ID, or medical information, but do provide details about your experience.

Follow-up Question
Would you like a patient advocate to follow up with you about your and/or
experience at ?
(Respondent has the option to check yes, is then prompted to provide email or phone #)

VA Outpatient Survey Questions FINAL | 4
3/16/2017

R.0 Race Question
To provide quality care and services, VA is also embarking on an effort to better understand
its customers. As part of this survey we would like to obtain additional information. The
following question is voluntary. By providing your data, your responses can help us improve
VA programs and services. Thank you for your participation.
Are you Hispanic or Latino?
o

Yes

o

No

What is your race? Select one or more.
❏ American Indian or Alaska Native
❏ Asian
❏ Black or African American
❏ Native Hawaiian or Other Pacific Islander
❏ White

VA Outpatient Survey Questions FINAL | 5
3/16/2017