Form VA Form 10-1465-2 VA Form 10-1465-2 SHEP Inpatient Short Form

OMB Number 2900-0712
Est. Burden: 14 minutes
VA Form 10-1465-2

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS: SHEP
RECENTLY DISCHARGED INPATIENT 2021
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 before being reported. However,
any additional information which you provide including comments written in the margins,
letters, and other enclosures will be shared with my office unless you indicate that you want
your comments to remain confidential and not be shared. If you would like to see the results of
the survey for all Veterans who get care at this facility, you may contact the Patient Advocate at
this facility.
Participation is voluntary and your answers to the survey will not affect the health care 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 14 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.

*** ABOUT YOUR RECENT HOSPITAL STAY ***
We realize that you may receive care at more than one VA location. However, it is important that
you answer the questions in this survey based on your VA hospital stay described below:
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Facility:
Date of discharge:

SURVEY INSTRUCTIONS


You should only fill out this survey if you were the patient during the hospital stay named in
the cover letter. Do not fill out this survey if you were not the patient.



Answer all the questions by checking 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
 No  If No, Go to Question 1
You may notice a number on the survey. This number is used to let us know if you
returned your survey so we don't have to send you reminders.
Please note: Questions 1-29 in this survey are part of a national initiative to measure the
quality of care in hospitals. OMB #2900-0712
Please answer the questions in this
survey about your stay at the hospital
named on the cover letter. Do not
include any other hospital stays in your
answers.

3. During this hospital stay, how often
did nurses explain things in a way
you could understand?





YOUR CARE FROM NURSES
1. During this hospital stay, how often
did nurses treat you with courtesy
and respect?





4. During this hospital stay, after you
pressed the call button, how often
did you get help as soon as you
wanted it?

Never
Sometimes
Usually
Always







2. During this hospital stay, how often
did nurses listen carefully to you?





Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always
I never pressed the call button

YOUR CARE FROM DOCTORS
5. During this hospital stay, how often
did doctors treat you with courtesy
and respect?





2

Never
Sometimes
Usually
Always

IPS_SHEP_IP_SVY_ENG_01.21

11. How often did you get help in getting
to the bathroom or in using a bedpan
as soon as you wanted?

6. During this hospital stay, how often
did doctors listen carefully to you?





Never
Sometimes
Usually
Always






7. During this hospital stay, how often
did doctors explain things in a way
you could understand?





12. During this hospital stay, were you
given any medicine that you had not
taken before?

Never
Sometimes
Usually
Always

 Yes
 No  If No, Go to Question 15
13. Before giving you any new medicine,
how often did hospital staff tell you
what the medicine was for?

THE HOSPITAL ENVIRONMENT






8. During this hospital stay, how often
were your room and bathroom kept
clean?





Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

14. Before giving you any new medicine,
how often did hospital staff describe
possible side effects in a way you
could understand?

9. During this hospital stay, how often
was the area around your room quiet
at night?





Never
Sometimes
Usually
Always






Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

WHEN YOU LEFT THE HOSPITAL
15. After you left the hospital, did you go
directly to your own home, to
someone else’s home, or to another
health facility?

YOUR EXPERIENCES IN THIS HOSPITAL
10. During this hospital stay, did you
need help from nurses or other
hospital staff in getting to the
bathroom or in using a bedpan?

 Own home
 Someone else’s home
 Another health facility  If
Another, Go to Question 18

 Yes
 No  If No, Go to Question 12

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16. During this hospital stay, did
doctors, nurses or other hospital
staff talk with you about whether you
would have the help you needed
when you left the hospital?

UNDERSTANDING YOUR CARE WHEN
YOU LEFT THE HOSPITAL
20. During this hospital stay, staff took
my preferences and those of my
family or caregiver into account in
deciding what my health care needs
would be when I left.

 Yes
 No
17. During this hospital stay, did you get
information in writing about what
symptoms or health problems to
look out for after you left the
hospital?






 Yes
 No

21. When I left the hospital, I had a good
understanding of the things I was
responsible for in managing my
health.

OVERALL RATING OF HOSPITAL
Please answer the following questions
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.






18. Using any number from 0 to 10,
where 0 is the worst hospital
possible and 10 is the best hospital
possible, what number would you
use to rate this hospital during your
stay?












Strongly disagree
Disagree
Agree
Strongly agree

22. When I left the hospital, I clearly
understood the purpose for taking
each of my medications.






0 Worst hospital possible
1
2
3
4
5
6
7
8
9
10 Best hospital possible

Strongly disagree
Disagree
Agree
Strongly agree
I was not given any medication
when I left the hospital
ABOUT YOU

There are only a few remaining items
left.
23. During this hospital stay, were you
admitted to this hospital through the
Emergency Room?

19. Would you recommend this hospital
to your friends and family?





Strongly disagree
Disagree
Agree
Strongly agree

 Yes
 No

Definitely no
Probably no
Probably yes
Definitely yes
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24. In general, how would you rate your
overall health?






29. What language do you mainly speak at
home?

Excellent
Very good
Good
Fair
Poor










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

Excellent
Very good
Good
Fair
Poor

English
Spanish
Chinese
Russian
Vietnamese
Portuguese
German
Some other language (please print):

_______________________________
Questions 1-29 in this survey are from the
U.S. Department of Health and Human
Services (HHS) for use in quality
measurement. The following questions
are from VA to gather additional feedback
about your hospital stay and will not be
shared with HHS.

26. 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

FURTHER QUESTIONS ABOUT
YOUR EXPERIENCE
30. During this hospital stay, how often
was personal information about you
treated in a confidential manner?

27. Are you of Spanish, Hispanic or Latino
origin or descent?






 No, not Spanish/Hispanic/Latino
 Yes, Puerto Rican
 Yes, Mexican, Mexican American,
Chicano
 Yes, Cuban
 Yes, other Spanish/Hispanic/Latino

Never
Sometimes
Usually
Always

31. During this hospital stay, were
providers willing to talk to your
family or friends about your health
or treatment?

28. What is your race? Please choose one
or more.

 Yes
 No

White
Black or African American
Asian
Native Hawaiian or other Pacific
Islander
 American Indian or Alaska Native






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32. During this hospital stay, how often
did you have a hard time speaking
with or understanding your doctors
or other health providers because
you spoke different languages?





37. During this hospital stay, when there
was more than one choice for your
treatment or health care, did providers
ask which choice you thought was best
for you?

Never
Sometimes
Usually
Always

 Yes
 No
38. During this hospital stay, did providers
talk with you about the pros and cons
of each choice for your treatment or
health care?

33. If you could have free care outside
the VA, would you choose to be
hospitalized here again?





 Yes
 No

Definitely would not
Probably would not
Probably would
Definitely would

ABOUT COMMUNICATING WITH VA
39. Did you have a complaint about how
you were treated (medically or
personally) during your last
hospitalization?

34. During this hospital stay, how often
did healthcare providers seem
informed and up-to-date about the
care you got from other providers at
the hospital?





 Yes
 No  Go to Question 45

Never
Sometimes
Usually
Always

40. If you reported this complaint to
someone at the VA location where you
received your care, to whom did you
report this complaint?
 Treatment team  Go to
Question 42
 Patient advocate  Go to
Question 42
 Other VA staff  Go to
Question 42
 Did not report the complaint to a VA
employee

35. Were there times when you were
confused because different
providers told you different things?
 Yes, always
 Yes, sometimes
 No
36. Did you know who to ask when you had
questions about your health care?
 Yes, always
 Yes, sometimes
 No

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41. If you did not report this complaint,
what was the most important reason
you did not report it? (Please mark
only one.)

44. How long did it take for the VA hospital
to resolve your complaint?








 I didn't know where to complain
 I was afraid of what would happen if
I did complain
 I thought complaining wouldn't do
any good
 I wasn't sure I had the right to
complain
 Other

FURTHER QUESTIONS ABOUT YOU
45. What is your gender?

42. If you had a complaint, how easy was it
for you to find someone to hear your
complaint?













Very easy
Easy
Difficult
Very difficult
Not applicable

Man
Woman
Transgender Man
Transgender Woman
Non-binary
Other

46. Do you consider yourself to be:

43. If you spoke with someone at the VA
location about a complaint, how
satisfied were you with the way your
complaint was handled?






Same day
2-7 days
8-14 days
15-21 days
More than 21 days
Complaint is not resolved
Not applicable








Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
Not applicable

Heterosexual or straight
Gay
Lesbian
Bisexual
Other
I am not sure

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

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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. Healthcare 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 this VA medical center, either contact the department that you think can help
you or ask for the Patient Advocate.
If you have a specific question about this survey, call 1-866-594-5444.
If you have a specific question about something other than this survey, please refer to the
contact options above.

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

Questions 1-19 and 23-29 are part of the HCAHPS Survey and are works of the U.S.
Government. These HCAHPS questions are in the public domain and therefore are NOT
subject to U.S. copyright laws. The three Care Transitions Measure® questions
(Questions 20-22) are copyright of Eric A. Coleman, MD, MPH, all rights reserved.

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