Form Attachment 21 Attachment 21 Attachment 21 Veteran SAQ

Form
OMB#
Exp. Date XX/XX/XXXX

Understanding Veterans’ Health Care Needs
This survey is about understanding the health care needs and utilization of military
veterans. Please take a few minutes to answer the questions in this booklet.

Survey Instructions

 Please answer each question by marking the answer boxes as indicated . If you are unsure
about how to answer a question, please give the best answer you can.

 You are sometimes told to skip over some question in this form. When this happens, you will see
arrows that tell you what question to go to next, like this:
Yes
No  GO TO Question 4

Next Question
 Your participation is voluntary and all of your answers will be kept confidential to the extent
permitted by law. If you have any question about this booklet, please call at .
 When you have completed the survey, place it in the envelope provided and give it to your
interviewer.

This Booklet
Should Be
Completed By →

REGION:

RUID:

PID:

NAME: ____________________________________________
DOB:

/

/

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of Public
Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to
that disclosure. Public reporting burden for this collection of information is estimated to average 7 minutes per response, he estimated time required to
complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimated or any other aspect of this collection of information, including
suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attentions: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 5600 Fishers
Lane, Room #07W42, Rockville, MD 20857.

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Start Here

Military History

► This first section asks about your military history.
1. Have you ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?




No, never served in the military

Please stop. Thank you for your
time. This survey is complete.

Yes, but only on active duty for training
in the Reserves or National Guard




Yes, and I am still on active duty
Yes, I was on active duty in the past, but not now

2. When did you serve on active duty in the U.S. Armed Forces?
Please mark yes for each period in which you served, even if it was just for part of the period. Mark no
if you did not serve any part of the period listed.
Yes No
a. September 2001 or later ........................................................................................
a1. IF YES to a, did you serve in a combat theater of operations during this time?
b. August 1990 to August 2001, including the Persian Gulf War ...............................
b1. IF YES to b, did you serve in a combat theater of operations after
November 11, 1998? ......................................................................................
b2. IF YES to b, did you serve in southwest Asia between August 2, 1990 and
November 11, 1998? ......................................................................................
c. June 1975 to July 1990 ...........................................................................................
d. February 1961 to May 1975 (Vietnam era) ............................................................
e. February 1955 to January 1961 ..............................................................................
f.

July 1950 to January 1955 (Korean War) ...............................................................

g. January 1947 to June 1950 .....................................................................................
h. December 1941 to December 1946 (World War II) ..............................................
i.

November 1941 or earlier ......................................................................................

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3. Do you have a VA service-connected disability rating?




Yes
No  GO TO Question 5

4. What is your VA service-connected disability rating?







0 percent
10 or 20 percent
30 or 40 percent
50 or 60 percent
70 percent or higher

5. Were you discharged or retired from the military for a disability incurred in the line of duty?




Yes
No

6. Are you a Purple Heart award recipient?




Yes
No

7. Are you a former prisoner of war (POW)?




Yes
No

8. What type of discharge did you receive when you were released from military service?








Honorable Discharge
General Discharge under Honorable Conditions
Other than Honorable (OTH) Discharge
Bad Conduct Discharge
Dishonorable Discharge
Administrative/entry-level separation

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Your Health and Health Care Services
► This section is about your health conditions that you may have now or had in the past.
9. Has a doctor or other health provider ever told you that you have any of the following?
Check Yes or No for each row.

Yes

General Conditions
a. COPD (Chronic Obstructive Pulmonary Disease) ..................................................
b. Dermatological conditions....................................................................................
c. GERD (Gastroesophageal reflux disease) .............................................................
d. Hearing loss ..........................................................................................................
Musculoskeletal Conditions
e. Back pain...............................................................................................................
f.

Joint pain...............................................................................................................

g. Osteoarthritis........................................................................................................
h. Gout ......................................................................................................................
i.

Neck pain ..............................................................................................................

j.

Fibromyalgia .........................................................................................................

k. TMD (Temporomandibular Joint Dysfunction) .....................................................
l.

Lupus.....................................................................................................................

Mental Health Conditions
m. PTSD (Post-traumatic Stress Disorder) .................................................................
n. Alcohol abuse .......................................................................................................
o. Drug abuse ............................................................................................................
p. Schizophrenia .......................................................................................................
q. Bipolar disorder ....................................................................................................
r.

Depression ............................................................................................................

s. Other mood disorder ............................................................................................

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No

10. Since discharge from military service, have you received any of the following services?
If yes for any service, indicate whether received from the VA and/or outside of the VA, otherwise
select no if you did not receive the listed services.
Yes,
from the VA

Yes,
outside the VA

No .

a. Prosthesis ...........................................................................
b. Rehabilitation services .......................................................
c. Individual mental health care.............................................
d. Group counseling for mental health care ..........................
e. Prescription medications....................................................
f.

Caregiver support ...............................................................

g. Assistive mobility devices
(e.g., wheelchairs, scooters, walkers, canes) .....................
11. A primary care provider is the health provider you see most often and who knows you best. How
much of a factor are each of the following to you in choosing a primary care provider?
Check one response for each row.
Major factor

a. The cost of care ...........................................
b. The recommendation of another doctor ....
c. The reputation of the personal doctor
providing the care .......................................
d. Short wait time for appointments...............
e. Location of the doctor’s practice ................
f.

The doctor is in my health plan’s provider
network .......................................................

g. The doctor understands the special needs
of veterans...................................................

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Minor factor

Not a factor

Don’t know

Health Care From Outside the VA
► This section is about health care you received from outside of the VA. This includes any visit to a
doctor, hospital, or clinic for health care that was not at a VA facility.
Do not include dental care.
12. Did you visit any health care provider outside of the VA in the last 12 months?




Yes
No  GO TO Question 19 on page 7

► For these next questions, please only think about the non-VA health care provider you saw most often
in the last 12 months.
13. In the last 12 months, how often did your non-VA health care provider know about your past
health problems or past treatments?






Never
Sometimes
Usually
Always

14. In the last 12 months, how often did your non-VA provider’s office keep health information about
you complete and up-to-date?






Never
Sometimes
Usually
Always

15. In the last 12 months, did you ask someone in your non-VA provider’s office for your medical
records?




Yes
No  GO TO Question 17 on page 7

16. In the last 12 months, when you asked someone at your non-VA provider’s office for your medical
records, how often did you get them as soon as you needed?






Never
Sometimes
Usually
Always

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17. Is your non-VA provider aware of the health care services you received at the VA in the last 12
months?





I did not receive any health care services
at the VA In the last 12 months

Please stop. Thank you for your
time. This survey is complete

Yes  GO TO Question 19
No

18. Sometimes, health care providers need to be aware of services you receive from others to
coordinate your care. How much of a problem was it that your non-VA provider was not aware of
the services you received at the VA?





Not a problem
A small problem
A big problem

Health Care at the VA
► This section is about health care services you received at a VA facility. This includes visits to a VA
doctor, hospital, or clinic for health care.
19. In the last 12 months, have you received any care from a VA provider? This includes any health care
you received at a VA facility. Do not include dental visits.




Yes
No 

Please stop. Thank you for your
time. This survey is complete

20. Do you have a primary care provider or Patient Aligned Care Team (PACT) at the VA who you have
visited in the last 12 months?
A Patient Aligned Care Team, or PACT, includes your primary care provider, nurse care manager,
clinical associate, and administrative clerk.




Yes
No  GO TO Question 31 on page 10

► These next questions are about your experience with your VA primary care provider/PACT.
21. In the last 12 months, how often did your VA primary care provider/PACT know about your past
health problems or past treatments?






Never
Sometimes
Usually
Always

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22. In the last 12 months, did you see a VA health care provider other than your VA primary care
provider/PACT?




Yes
No  GO TO Question 24

23. In the last 12 months, how often did your VA primary care provider/PACT know about any tests or
results from visits to other VA health care providers?






Never
Sometimes
Usually
Always

24. In the last 12 months, how often did your VA primary care provider/PACT keep health information
about you complete and up-to-date?






Never
Sometimes
Usually
Always

25. In the last 12 months, did you ask your VA primary care provider/PACT for your medical records?




Yes
No  GO TO Question 27 on page 9

26. In the last 12 months, when you asked your VA primary care provider/PACT for your medical
records, how often did you get them as soon as you needed?






Never
Sometimes
Usually
Always

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27. In the last 12 months, did you need a referral from your VA primary care provider/PACT to see a
non-VA health provider?




Yes
No  GO TO Question 29

28. In the last 12 months, when you needed a referral from your VA primary care provider/PACT to see
a non-VA health care provider, how often did you get a referral as soon as you needed it?






Never
Sometimes
Usually
Always

29. Is your VA primary care provider/PACT aware of the health care services you received outside the
VA in the last 12 months?





I did not receive any health care services
outside the VA in the last 12 months

GO TO Question 31 on page 10

Yes
No

30. Sometimes, health care providers need to be aware of services you receive from others to
coordinate your care. How much of a problem was it that your VA primary care provider/PACT was
not aware of services you received outside the VA?





Not a problem
A small problem
A big problem

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Health Care From Specialists
► This section is about health care services you received from a specialist.
Specialists are doctors like surgeons, heart doctors, psychiatrists, allergy doctors, skin doctors, and
other doctors who specialize in one area of health care.
31. In the last 12 months, did you receive care from any VA specialist other than you VA primary care
provider/PACT?




Yes
No 

Please stop. Thank you for your
time. This survey is complete

► The following questions ask about care you received from the VA specialist you saw most often in the
last 12 months other than your VA primary care provider/PACT.
32. When you saw this VA health care specialist, did he or she have enough information about your
medical history?




Yes
No

33. Was this VA specialist aware of the health care services you received outside the VA in the last 12
months?



I did not get any health services from

Please stop. Thank you for your
time. This survey is complete

non-VA providers in the last 12 months




Yes
No

34. Sometimes, health care providers need to be aware of treatments you receive from others to
coordinate your care. How much of a problem was it that your VA specialist was not aware of
services you received outside the VA.





Not a problem
A small problem
A big problem

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Thank you for completing this survey!
Please place this completed survey in the envelope provided to you and
give it to your interviewer.
If the interviewer is no longer available, place the survey in the return
envelope provided to you by the interviewer. If the envelope is missing,
mail the survey to:
MEPS
c/o Westat
1600 Research Blvd, Room GA51
Rockville, MD 20850

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