Form 10-10070 Survey of Health Care Experiences of Patients - Dental P

OMB Number 2900-0764

Est. Burden: 15 minutes

VA Form 10-10070

Exp. Date: XX/XX/XXXX

SURVEY OF HEALTHCARE

EXPERIENCES OF PATIENTS

DENTAL CARE 2015

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.

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 0MB number. We anticipate that the time expended by all individuals who complete this survey will average 15 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.

Survey Instructions

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 see an arrow with a note that tells you what question to answer next, like this:

Yes  If Yes, go to #1 on page 1

No

1. In the last 12 months, did you go to a VA dentist’s office or clinic for care?

¹ Yes

² No  If No, please stop and
return this survey in the postage-paid envelope. Thank you.

About Your Health

2. In general, how would you rate the overall condition of your teeth and gums?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

3. In general, how would you rate your overall health?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

Your Regular Dentist

A “regular dentist” is one you would go to for check-ups and cleanings or when you have a cavity or tooth pain.

4. Do you have a regular VA dentist?

¹ Yes

² No  If No, go to #11

5. Have you seen your regular VA dentist in the last 12 months?

¹ Yes

² No, I’ve seen someone else  If No, go to #11

6. In the last 12 months, how often did your regular VA dentist explain things in a way that was easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

7. In the last 12 months, how often did your regular VA dentist listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

8. In the last 12 months, how often did your regular VA dentist treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

9. In the last 12 months, how often did your regular VA dentist spend enough time with you?

¹ Never

² Sometimes

³ Usually

⁴ Always

10. Using any number from 0 to 10, where 0 is the worst regular dentist possible and 10 is the best regular dentist possible, what number would you use to rate your regular VA dentist?

0 Worst regular dentist possible

1

2

3

4

5

6

7

8

9

10 Best regular dentist possible

Your Dental Care in the Last 12 Months

So far, the questions on this survey have been about your regular VA dentist. The next set of questions asks about all dental care you had in VA in the last 12 months.

11. In the last 12 months, how often did the dentists or dental staff do everything they could to help you feel as comfortable as possible during your dental work?

¹ Never

² Sometimes

³ Usually

⁴ Always

12. In the last 12 months, how often did the dentists or dental staff explain what they were doing while treating you?

¹ Never

² Sometimes

³ Usually

⁴ Always

13. In the last 12 months, how often were your dental appointments as soon as you wanted?

¹ Never

² Sometimes

³ Usually

⁴ Always

14. If you needed to see a dentist right away because of a dental emergency in the last 12 months, did you get to see a dentist as soon as you wanted?

⁰ I did not have a dental emergency in the last 12 months

¹ Definitely yes

² Somewhat yes

³ Somewhat no

⁴ Definitely no

15. If you were advised to get an appointment for yourself with a dentist who specializes in a particular type of dental care (such as root canals or gum disease) in the last 12 months, how often did you get an appointment as soon as you wanted?

⁰ I did not try to get an appointment with a specialist dentist for myself in the last 12 months

¹ Never

² Sometimes

³ Usually

⁴ Always

16. In the last 12 months, how often did you have to spend more than 15 minutes in the waiting room after your scheduled appointment time before you saw someone?

¹ Never  If Never, go to #18

² Sometimes

³ Usually

⁴ Always

17. If you had to spend more than 15 minutes in the waiting room after your scheduled appointment time, how often did someone tell you why there was a delay or how long the delay would be?

¹ Never

² Sometimes

³ Usually

⁴ Always

18. Using any number from 0 to 10, where 0 is the worst dental care possible and 10 is the best dental care possible, what number would you use to rate all of the VA dental care you personally received in the last 12 months?

0 Worst dental care possible

1

2

3

4

5

6

7

8

9

10 Best dental care possible

19. A dental provider could be a general dentist, a dental specialist, a dental hygienist, or a dental assistant. In the last 12 months, how often did you and a VA dental provider talk about specific things you could do to prevent dental problems?

¹ Never

² Sometimes

³ Usually

⁴ Always

20. Sometimes there can be different options in dental care for your dental treatment or preventive dental care. In the last 12 months, did a VA dental provider tell you there was more than one choice for your dental treatment or care?

¹ Yes

² No  If No, go to #23.

21. In the last 12 months, did a VA dental provider talk with you about the pros and cons of each choice for your dental treatment or care?

¹ Definitely yes

² Somewhat yes

³ Somewhat no

⁴ Definitely no

22. In the last 12 months, when there was more than one choice for your dental treatment or care, did a VA dental provider ask which choice was best for you?

¹ Definitely yes

² Somewhat yes

³ Somewhat no

⁴ Definitely no

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

¹ Routine cleaning, check-up or examination

² Treatment of a problem my dentist discovered at an earlier check-up or examination

³ Treatment related to dentures (false teeth)

⁴ Something was wrong, hurting or bothering me

⁵ Don’t know / don’t remember

⁶ Other

24. In the last 12 months, how often did you have a hard time speaking with or understanding your VA dental provider because you spoke different languages?

¹ Never

² Sometimes

³ Usually

⁴ Always

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

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

	Poor	Fair	Good	Very Good	Excellent	Does Not Apply
Cleanliness of the room	1□	2□	3□	4□	5□	6□
b. Privacy while in the room	1□	2□	3□	4□	5□	6□
c. Noise level	1□	2□	3□	4□	5□	6□
d. Sense of safety and security	1□	2□	3□	4□	5□	6□

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

	Poor	Fair	Good	Very Good	Excellent	Does Not Apply
a. Cleanliness of the reception/waiting area	1□	2□	3□	4□	5□	6□
b. Cleanliness of the restroom/lavatory	1□	2□	3□	4□	5□	6□
c. Availability of parking	1□	2□	3□	4□	5□	6□
d. How would you rate the clinic building overall (i.e. attractiveness of facility appearance, quality of building maintenance and upkeep)?	1□	2□	3□	4□	5□	6□
e. In terms of your satisfaction, how would you rate the convenience of the location of the clinic facility?	1□	2□	3□	4□	5□	6□

Dental Coverage and Eligibility

The next question asks about your dental coverage or eligibility within VA. Answer only about your VA dental coverage and eligibility.

27. In the last 12 months, how often did your VA dental coverage or eligibility cover all of the dental services you thought should be covered?

¹ Never

² Sometimes

³ Usually

⁴ Always

About You

28. What is your age?

¹ 18 to 24

² 25 to 34

³ 35 to 44

⁴ 45 to 54

⁵ 55 to 64

⁶ 65 to 74

⁷ 75 to 84

⁸ 85 or older

29. Are you male or female?

¹ Male

² Female

30. What is the highest grade or level of school that you have completed?

¹ 8th grade or less

² Some high school, but did not graduate

³ High school graduate or GED

⁴ Some college or 2-year degree

⁵ 4-year college graduate

⁶ More than 4-year college degree

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

¹ Yes, Hispanic or Latino

² No, not Hispanic or Latino

³ I choose not to answer this question

32. What is your race? (Please mark one or more.)

¹ White

² Black or African-American

³ Asian

⁴ Native Hawaiian or other Pacific Islander

⁵ American Indian or Alaska Native

⁶ Other

⁷ I choose not to answer this question

33. Did someone help you complete this survey?

¹ Yes

² No  Thank you.
Please return the completed survey in the postage-paid envelope.

34. How did that person help you? Please check all that apply.

¹ Read the questions to me

² Wrote down the answers I gave

³ Answered the questions for me

⁴ Translated the questions into my language

⁵ Helped in some other way

If so, please explain here:

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 veteran’s 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.

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 XXXXXX

P.O. Box 806046

Chicago, IL 60680

Patient Satisfaction Survey – Print Version – 2/18/2015 Page 2