VA Form 10-1465-6 SHEP Patient Centered Medical Homes (PCMH) Long Form 10-

OMB Number 2900-0712
Est. Burden: 21 minutes
Exp. Date 03/31/2017
VA Form 10-1465-6

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
AMBULATORY CARE 2016
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.
The check-box 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. However, any additional 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 way to address your concerns, unless you instruct us not to.
Participation is voluntary and your answers to the survey will not affect the healthcare you receive or
your eligibility for VA benefits.
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 OMB number. We anticipate that the time
expended by all individuals who complete this survey will average 21 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.

Version: 45 – 0416

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
No

YOUR PROVIDER
1.

Our records show that you got care from
the provider named below in the last 6
months.
[PROVIDER NAME]
Is that right?




YOUR CARE FROM THIS PROVIDER IN
THE LAST 6 MONTHS
These questions ask about your own health
care. Do not include care you got when you
stayed overnight in a hospital. Do not include
the times you went for dental care visits.
4.

Yes









NoIf No, go to #59

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

Is this the provider you usually see if you
need a check-up, want advice about a
health problem, or get sick or hurt?



3.

Yes

5.

No

How long have you been going to this
provider?







At least 1 year but less than 3 years
At least 3 years but less than 5 years

5 years or more

6.

None If None, go to #44
1 time
2
3
4
5 to 9
10 or more times

In the last 6 months, did you contact this
provider’s office to get an appointment for
an illness, injury or condition that needed
care right away?




Less than 6 months
At least 6 months but less than 1 year

In the last 6 months, how many times did
you visit this provider to get care for
yourself?

Yes
NoIf No, go to #8

In the last 6 months, when you contacted
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?






Never
Sometimes
Usually
Always

7.

In the last 6 months, how many days did
you usually have to wait for an appointment
when you needed care right away?






8.

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

In the last 6 months, did you make any
appointments for a check-up or routine
care with this provider?



9.

Same day

Yes
No If No, go to #10

In the last 6 months, when you made an
appointment for a check-up or routine care
with this provider, how often did you get an
appointment as soon as you needed?






Never
Sometimes
Usually
Always

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




Yes
No

11. In the last 6 months, did you need care for
yourself during evenings, weekends, or
holidays?




Yes
No If No, go to #13

12. In the last 6 months, how often were you
able to get the care you needed from this
provider’s office during evenings,
weekends, or holidays?






Never
Sometimes
Usually
Always

13. In the last 6 months, did you contact this
provider’s office with a medical question
during regular office hours?




Yes
No If No, go to #15

14. In the last 6 months, when you contacted
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

15. In the last 6 months, did you contact this
provider’s office with a medical question
after regular office hours?




Yes

No If No, go to #17

16. In the last 6 months, when you contacted
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

17. Some offices remind patients between
visits about tests, treatment or
appointments. In the last 6 months, did you
get any reminders from this provider’s
office between visits?




Yes
No

18. Wait time includes time spent in the waiting
room and exam room. In the last 6 months,
how often did you see this provider within
15 minutes of your appointment time?






Never
Sometimes
Usually
Always

19. In the last 6 months, how often did this
provider explain things in a way that was
easy to understand?






Never
Sometimes
Usually
Always

20. In the last 6 months, how often did this
provider listen carefully to you?






Never
Sometimes
Usually
Always

21. In the last 6 months, did you talk with this
provider about any health questions or
concerns?




Yes
No If No, go to #23

22. In the last 6 months, how often did this
provider give you easy to understand
information about these health questions
or concerns?






Never
Sometimes
Usually
Always

23. In the last 6 months, how often did this
provider seem to know the important
information about your medical history?






Never
Sometimes
Usually
Always

24. In the last 6 months, how often did this
provider show respect for what you had to
say?






Never
Sometimes
Usually
Always

25. In the last 6 months, how often did this
provider spend enough time with you?






Never
Sometimes
Usually
Always

26. In the last 6 months, did this provider order
a blood test, x-ray, or other test for you?




Yes
No If No, go to #28

27. In the last 6 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?






Never
Sometimes
Usually
Always

28. In the last 6 months, did you and this
provider talk about starting or stopping a
prescription medicine?




Yes
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?






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?






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?




Yes
No

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?













0

Worst provider possible

1
2
3
4
5
6
7
8
9
10 Best provider possible

33. In the last 6 months, did you take any
prescription medicine?




Yes
No If No, go to #35

34. In the last 6 months, how often did you and
someone from this provider’s office talk
about all the prescription medicines you
were taking?






Never
Sometimes
Usually
Always

35. 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 6 months, did you
see a specialist for a particular health
problem?




Yes
No If No, go to #37

36. In the last 6 months, how often did the
provider named in Question 1 seem
informed and up-to-date about the care you
got from specialists?






Never
Sometimes
Usually
Always

Please answer these questions about the
provider named in Question 1 of the survey.
37. In the last 6 months, did anyone in this
provider’s office talk with you about
specific goals for your health?




Yes
No

38. In the last 6 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
No

39. In the last 6 months, did anyone in this
provider’s office ask you if there was a
period of time when you felt sad, empty or
depressed?




Yes
No

40. In the last 6 months, did you and anyone in
this provider’s office talk about things in
your life that worry you or cause you
stress?




Yes
No

41. In the last 6 months, did you and anyone in
this provider’s office talk about a personal
problem, family problem, alcohol use, drug
use, or a mental or emotional illness?




Yes
No

CLERKS AND RECEPTIONISTS AT THIS
PROVIDER’S OFFICE
42. In the last 6 months, how often were clerks
and receptionists at this provider’s office
as helpful as you thought they should be?






Never
Sometimes
Usually
Always

43. In the last 6 months, how often did clerks
and receptionists at this provider’s office
treat you with courtesy and respect?






Never
Sometimes
Usually
Always

YOUR CARE FROM SPECIALISTS
IN THE LAST 6 MONTHS
These questions ask about your own health
care. Do not include care you got when you
stayed overnight in a hospital. Do not include
the times you went for dental care visits.
44. 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 6 months, did you
try to make any appointments with a VA
specialist?




Yes
No If No, go to #46

45. In the last 6 months, how often was it easy
to get appointments with VA specialists?






Never
Sometimes

Usually
Always

46. In the last 6 months, did you try to make
any appointments with a Non-VA specialist
paid for by VA?




Yes
No If No, go to #48

47. In the last 6 months, how often was it easy
to get appointments with Non-VA specialist
paid for by VA?






Never
Sometimes
Usually
Always

48. Please think about your most recent visit
within the last 6 months to either a VA
specialist or Non-VA specialist. Was this
specialist:






A VA specialist
A non-VA specialist paid for by VA
A non-VA specialist seen on my own
Did not see a specialist in the last 6
months
Go to #51

49. During your most recent visit with the
specialist, did the specialist know
important information about your medical
history?





Yes, definitely
Yes, somewhat
No

50. 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 this specialist?













0

Worst specialist possible

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

USING THE VA PHARMACY
51. During the past 3 months, when you were
seen at [FACILITY NAME], did you visit the
pharmacy outpatient window to get your
prescription(s) filled?





Yes
No If No, go to #54
No pharmacy outpatient window at this
facility If No outpatient window,
go to #54

52. For each part of your VA pharmacy visit, please tell us the amount of improvement needed, if any:
No
Improvement
Needed

Slight
Improvement
Needed

Some
Improvement
Needed

A lot of
Improvement
Needed

Does
Not Apply







































































a. The length of time you waited
at the VA pharmacy
b. Questions were answered to
your satisfaction by pharmacy
staff
c. The courtesy of the VA
pharmacy staff
d. Personal privacy in the VA
pharmacy waiting room
e. VA pharmacy waiting room
comfort & cleanliness
f. Contacting the VA pharmacy
by phone when you have
questions about your
medication
g. Contacting your VA
healthcare provider when you
have questions about your
medication

53. Overall, how satisfied were you with
pharmacy services provided at the
[FACILITY NAME] pharmacy outpatient
window during the past three months?







Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

54. During the past 3 months, did you receive
medications or supplies from the VA
pharmacy in the mail?




Yes
No If No, go to #57

55. Please tell us about the medications or supplies you received from the VA pharmacy in the mail.
How often did these things happen to you?

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
56. Overall, how satisfied were you with VA
pharmacy services provided through the
mail during the past 3 months?







Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

ABOUT COMMUNICATING
WITH THE VA
57. In the last 6 months, did you have a
complaint about how you were treated
(medically or personally) during your
recent healthcare visit?




Yes
No

58. In the last 6 months, how often did you
have a hard time speaking with or
understanding your VA doctor or nurse
because you spoke different languages?






Never
Sometimes
Usually
Always

Never

Sometimes

Usually

Always

























































YOUR OVERALL EXPERIENCE WITH THE
DEPARTMENT OF VETERANS AFFAIRS
Now think about your experiences with all the
services provided by the Department of
Veterans Affairs (which include healthcare,
benefits programs, or memorial services).
Please tell us how you feel about the following
statements:
59. I got the service I needed.







Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

60. It was easy to get the service I needed.







Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

61. I felt like a valued customer.







Strongly disagree
Disagree
Neither agree nor disagree

Strongly agree

Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree

ABOUT YOU
63. In general, how would you rate your overall
health?







Excellent
Very Good
Good
Fair
Poor

64. In general, how would you rate your overall
mental or emotional health?







Excellent
Very Good
Good
Fair
Poor

65. Have you had either a flu shot or flu spray
in the nose since July 1, 2015?







Was told I was not eligible to get the flu
vaccine this year because of the shortage



Flu vaccine not available and I didn't get it
elsewhere



Medical advice not to get a flu shot (such
as allergy, illness)







No time/Didn't get around to it

Agree

62. I trust VA to fulfill our country’s
commitment to veterans.







66. If you did not get a flu vaccine in July 2015
or later, why not? Mark the MAIN reason:

Yes
No
Don’t know






Inconvenient to get it at the VA
Don't like needles/injections
I believe it might make me sick
Don't believe in it/Prefer other methods of
prevention
Did not think I needed a flu shot
Did not want a flu vaccine
I plan to get my flu vaccine at a later date
Other

67. Where did you get your flu vaccine?



At the VA (such as a hospital, clinic,
outreach mobile unit)




Vet Center
Non-VA hospital, clinic, doctor's office,
visiting nurse or Health Department



Community source (drug store, church,
grocery store, etc.)




Other
Do not remember

68. Have you ever had a pneumonia shot? This
shot is usually given only once or twice in a
person’s lifetime and is different from the
flu shot. It is also called the pneumococcal
vaccine.





Yes
No
Don’t know

69. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?






Every day
Some days
Not at all  If Not at all, Go to #73
Don’t know  If Don’t know, Go to #73

70. In the last 6 months, how often were you
advised to quit smoking or using tobacco
by a VA doctor or other VA health
provider?






Never
Sometimes
Usually
Always

71. In the last 6 months, how often was
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.






Never
Sometimes
Usually
Always

72. In the last 6 months, how often did your VA
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.






Never





Yes

Sometimes
Usually

Always
73. Do you take aspirin daily or every other day?

No
Don’t know

74. Do you have a health problem or take
medication that makes taking aspirin
unsafe for you?





Yes
No
Don’t know

75. Has a VA doctor or VA health provider ever
discussed with you the risks and benefits
of aspirin to prevent heart attack or stroke?




Yes
No

76. Are you aware that you have any of the
following conditions? Check all that apply.





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

77. Has a VA doctor ever told you that you
have any of the following conditions?
Check all that apply.






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

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








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

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




Yes, Hispanic or Latino
No, Not Hispanic or Latino

80. What is your race? Mark one or more.







82. Did someone help you complete this
survey?

White




Black or African-American
Asian

No 

Native Hawaiian or other
Pacific Islander

Thank you. Please return the
completed survey in the
postage-paid envelope.

83. How did that person help you? Mark one or
more.

American Indian or Alaska Native

81. What language do you mainly speak at
home?









Yes

English
Spanish
Chinese







Russian

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into
my language
Helped in some other way

Vietnamese
Portuguese
Some other language (please print):

__________________________

THANK YOU
Please return the completed survey in the postage-paid envelope.

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
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 Ipsos
P.O. Box 806046
Chicago, IL 60680