VA Form 10-1465-5 SHEP Patient Centered Medical Homes (PCMH) Short Form

OMB Number 2900-0712
Est. Burden: 12 minutes
VA Form 10-1465-5

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS: SHEP
PRIMARY CARE 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 12 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: 44 – 0421

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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 CARE FROM THIS PROVIDER
IN THE LAST 6 MONTHS

YOUR PROVIDER
1.

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.

Our records show that you got care
from the provider named below in the
last 6 months.

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4.

Is that right?




Yes









NoIf No, go to #55

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.

5.

Yes
No

How long have you been going to this
provider?




6.

At least 6 months but less than
1 year
At least 1 year but less than
3 years



At least 3 years but less than
5 years



5 years or more

1 time
2
3
4
5 to 9
10 or more times

Yes
NoIf 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?





2

None If None, go to #55

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



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

Never
Sometimes
Usually
Always
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7.






8.




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






Yes
No If No, go to #10




Sometimes
Usually
Always






Yes




Yes
No If No, go to #13

Usually
Always

Yes

No If No, go to #17

Never
Sometimes
Usually
Always

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?

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?






Sometimes

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?

No

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




Never

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

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




No If No, go to #15

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

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?






Yes

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?

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



9.

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

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






Never
Sometimes
Usually
Always
3

Never
Sometimes
Usually
Always
IPS_SHEP_PCMH-SHORT_SVY_ENG_01.21

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

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











Never
Sometimes
Usually




Never
Sometimes
Always






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

Yes
No If No, go to #28

Never
Sometimes
Usually
Always

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?

Usually
Always






Never
Sometimes
Usually

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?

Always

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






Always

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

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






Usually

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?

Usually

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




Sometimes

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

Always

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






Never






Never
Sometimes
Usually
Always
4

Not at all
A little
Some
A lot
IPS_SHEP_PCMH-SHORT_SVY_ENG_01.21

35. During your visits in the last 6 months,
did this provider ever use a computer
or handheld device to show you
information?

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

0





Worst provider possible

1
3





4
5
6

No
Don’t know

Yes, definitely
Yes, somewhat
No

38. During your visits in the last 6 months,
did this provider’s use of a computer or
handheld device make it harder or
easier for you to talk with him or her?

7
8
9





10 Best provider possible

Harder
Not harder or easier
Easier

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




Yes

Yes
No If No, go to #41

40. 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?

No If No, go to #39

34. During your visits in the last 6 months,
did this provider ever use a computer
or handheld device to look up test
results or other information about you?





Yes

37. During your visits in the last 6 months,
was this provider’s use of a computer
or handheld device helpful to you?

2

33. Providers may use computers or
handheld devices during an office visit
to do things like look up your
information or order prescription
medicines. In the last 6 months, did this
provider use a computer or handheld
device during any of your visits?




No

36. During your visits in the last 6 months,
did this provider ever use a computer
or a handheld device to order your
prescription medicines?

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?













Yes






Yes
No
Don’t know

5

Never
Sometimes
Usually
Always

IPS_SHEP_PCMH-SHORT_SVY_ENG_01.21

41. 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?




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




Yes
No If No, go to #43

48. 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

Please answer these questions about the
provider named in Question 1 of the survey.






Yes
No

44. In the last 6 months, did someone
from this provider’s office ask you if
there are things that make it hard for
you to take care of your health?




Yes
No

Usually
Always

Never
Sometimes
Usually
Always

Next, we would like to learn more about
the contacts that you may have had with
this provider’s office other than face-toface appointments.
50. In the last 6 months, did you use
secure messaging online to contact

Yes

this provider’s office?

No





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




Sometimes

CONTACTING THIS PROVIDER’S OFFICE
BY SECURE MESSAGING OR TELEPHONE

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




Never

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

43. In the last 6 months, did someone
from this provider’s office talk with
you about specific goals for your
health?




No

CLERKS AND RECEPTIONISTS AT
THIS PROVIDER’S OFFICE

42. 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?






Yes

Yes
No If No, go to #52
I am not sure If not sure, go to #52

Yes
No
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IPS_SHEP_PCMH-SHORT_SVY_ENG_01.21

ABOUT YOU

51. In the last 6 months, when you
contacted this provider’s office using
secure messaging, how often did you
get a helpful response as soon as you
needed?






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







Never
Sometimes
Usually
Always

52. In the last 6 months, did you phone
this provider’s office?




Yes







No If No, go to #54

Never

Good
Fair
Poor

Excellent
Very Good
Good
Fair
Poor

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

Sometimes
Usually
Always

YOUR OVERALL EXPERIENCE WITH
VA HEALTH CARE
54. Overall, how satisfied are you with the
health care you have received at your
VA facility during the last 6 months?








Very Good

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

53. In the last 6 months, when you
phoned this provider’s office, how
often did you get a helpful response
as soon as you needed?






Excellent

Very Dissatisfied




8th grade or less






High school graduate or GED

Some high school, but did not
graduate
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

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

Dissatisfied
Somewhat Dissatisfied




Somewhat Satisfied

Satisfied

Yes, Hispanic or Latino
No, Not Hispanic or Latino

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

Very Satisfied

7






White



American Indian or Alaska Native  

Black or African-American
Asian
Native Hawaiian or other
Pacific Islander

IPS_SHEP_PCMH-SHORT_SVY_ENG_01.21

62. Do you consider yourself to be:

60. What language do you mainly speak at
home?
















English
Spanish
Chinese
Russian
Vietnamese
Portuguese

Gay
Lesbian
Bisexual
Other
I am not sure

63. Did someone help you complete this
survey?

Some other language (please print):

__________________________




61. What is your gender?








Heterosexual or straight

Man
Woman
Transgender Man

Yes
No 

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

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

Transgender Woman
Non-binary
Other






Read the questions to me



Helped in some other way

Wrote down the answers I gave
Answered the questions for me
Translated the questions into
my language

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. 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.

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

8

IPS_SHEP_PCMH-SHORT_SVY_ENG_01.21