Form 10-10070 Dental Care Patient Satisfaction Survey (SHEP)

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

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OMB Number 2900-0764
Est. Burden: 15 minutes
VA Form 10-0503

Yes, Hispanic or Latino
No, not Hispanic or Latino

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
DENTAL CARE 2021

I choose not to answer this question

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

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White
Black or African-American

In order for the VA to carry out its mission to provide the best possible medical care and services to eligible
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.

Asian
Native Hawaiian or other Pacific Islander

We want to remind you that all information is strictly anonymous. 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.

American Indian or Alaska Native
I choose not to answer this question

33. Did someone help you complete this survey?

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Yes
No  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 as described at the end of
this survey booklet.

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

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Read the questions to me

Thank you very much!

Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
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. Healthcare 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. Any enclosed information
will be sent with this survey to the Medical Center Director. 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

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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 O MB 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.

*** YOUR RECENT VISIT TO A VA DENTAL FACILITY ***
Our records show that you recently visited the VA facility described below. You will be asked to refer to this
information later in the survey:

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

SURVEY INSTRUCTIONS
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 
1.

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

ABOUT YOUR HEALTH
2.

3.

Excellent
Good

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Fair
Poor

5.

Does Not
Apply

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Sometimes
Usually
Always

ABOUT YOU

Very good

28. What is your age?

Good
Fair
Poor

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18 to 24
25 to 34
35 to 44
45 to 54

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55 to 64
65 to 74
75 to 84
85 or older

29. Are you male or female?

Do you have a regular VA dentist?

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Yes
No  If No, go to #11

Male
Female

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

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

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Excellent

Never

Excellent

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

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Very
Good

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?

Very good

YOUR REGULAR DENTIST
4.

Good

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

In general, how would you rate your overall health?

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Fair

DENTAL COVERAGE AND ELIGIBILITY

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

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b. Cleanliness of the restroom/lavatory
c. Availability of parking
d. How would you rate the clinic building
overall (i.e. attractiveness of facility
appearance, quality of building
maintenance and upkeep)?
e. In terms of your satisfaction, how would
you rate the convenience of the location of
the clinic facility?

If No, go to question 1

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

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a. Cleanliness of the reception/waiting area

Poor

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Yes
No, I’ve seen someone else  If No, go to #11

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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
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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?

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Somewhat yes
Somewhat no
Definitely no

Somewhat no
Definitely no

8.

Treatment of a problem my dentist discovered at an earlier check-up or examination
Treatment related to dentures (false teeth)
Something was wrong, hurting or bothering me

9.

Don’t know / don’t remember
Other

Never
Sometimes
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
b. Privacy while in the room
c. Noise level
d. Sense of safety and security

Usually
Always

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

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

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Never
Sometimes
Usually
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?

Usually

a. Cleanliness of the room

Sometimes

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

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Routine cleaning, check-up or examination

Never

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

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Somewhat yes

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?

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7.

Definitely yes

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

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

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Definitely yes

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?

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6.

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Fair

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Good

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Very
Good

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Excellent

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Does Not
Apply

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

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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?

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Never
Usually
Always

Never
Usually
Always

Never
Sometimes
Usually
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?

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I did not have a dental emergency in the last 12 months
Definitely yes
Somewhat yes

Sometimes
Usually
Always

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Never
Sometimes
Usually
Always

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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?

Somewhat no
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?

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Never  If Never, go to #18

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?

Sometimes

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

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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?

Sometimes

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

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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?

I did not try to get an appointment with a specialist dentist for myself in the last 12 months
Never

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Never
Sometimes
Usually
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?

Sometimes
Usually
Always

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Yes
No  If No, go to #24
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