JOES-C Questionnaire_Revised_10.3.2024

LICENSE TO ADMINISTER: Report

RCS: DD-HA (D) 2598

Expires: June 30, 2025

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PRIVACY STATEMENT

This statement serves to inform you of the purpose for collecting personal information as required by the Privacy Act of 1974, as amended, and how that information will be stored and used.

Authority: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C., Ch. 55, Medical and Dental Care; 45 CFR 164, Security and Privacy; Department of Defense (DoD) Instruction 6015.23, Foreign Military Personnel Care and Uniform Business Offices in Military Treatment Facilities (MTFS); DoD Manual 6025.18, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs; and E.O. 9397 (SSN), as amended.

Purpose: The JOES Survey Suite is a survey system used by the military to gather feedback about outpatient care. The surveys help measure patient satisfaction and guide efforts to make the health system better.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: to contractors and others performing or working for the Federal Government when necessary to accomplish an agency function related to this System of Records; For a complete listing of the Routine Uses for this system, refer to the below hyperlinked SORN.

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Rules, as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

Applicable SORN: EDHA 07, Military Health Information System (June 15, 2020; 85 FR 36190) https://dpcld.defense.gov/Portals/49/ Documents/Privacy/SORNs/DHA/EDHA-07.pdf

Disclosure: Voluntary, Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if you choose not to respond, although maximum participation is encouraged so the data will be complete and representative.

Providing information in this survey is voluntary. There is no penalty nor will your benefits be affected if you choose not to respond.

However, maximum participation is encouraged so that the data will be complete and representative. Your survey response will be treated as confidential, identifying information will be used only by persons engaged in, and for the purposes of, the survey research.

However, if during this survey you indicate a direct threat to harm yourself or others, we are required to forward information about that threat to appropriate authorities for action, which will likely include their contacting you.

Please use pen or dark pencil to mark an “X” in the answer box:

Example: Correct Incorrect

YOUR PROVIDER

1. Visits with a health care provider can be in person, by phone, or by video. Our records show that you had a recent visit with the provider named below.

(PROVIDER)

Is that right?

• Yes

• No Go to Question 24 on page 3

Please think of this provider as you answer the survey.

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

• Yes

• No

3. How long has it been since your most recent in-person, phone, or video visit with this provider?

• Less than 1 month

• At least 1 month but less than 3 months

• At least 3 months but less than 6 months

• At least 6 months but less than 1 year

• 1 year or more

These questions ask about your most recent visit with this provider.

4. Was your most recent visit with this provider in person?

• Yes Go to Question 11 on page 2

• No

5. Was your most recent visit with this provider a video visit?

• Yes

• No Go to Question 9 on page 2

6. Did you need instructions from this provider’s office about how to use video for this visit?

• Yes

• No Go to Question 8

7. Did this provider’s office give you all the instructions you needed to use video for this visit?

• Yes, definitely

• Yes, somewhat

• No

8. During your most recent visit, was the video easy to use?

• Yes, definitely Go to Question 10

• Yes, somewhat Go to Question 10

• No Go to Question 10

9. Was your most recent visit with this provider by phone?

• Yes

• No Go to Question 11

10. During your most recent visit, were you and this provider able to hear each other clearly?

• Yes, definitely

• Yes, somewhat

• No

11. Did your healthcare team begin to address your needs within 30 minutes of your appointment time?

• Yes

• No

12. Was your most recent visit for an illness, injury, or condition that needed care right away?

• Yes

• No Go to Question 14

13. Was that recent visit as soon as you needed?

• Yes, definitely

• Yes, somewhat

• No

14. Did your most recent visit start on time?

• Yes, definitely

• Yes, somewhat

• No

15. During your most recent visit, did this provider explain things in a way that was easy to understand?

• Yes, definitely

• Yes, somewhat

• No

16. During your most recent visit, did this provider listen carefully to you?

• Yes, definitely

• Yes, somewhat

• No

17. During your most recent visit, did this provider show respect for what you had to say?

• Yes, definitely

• Yes, somewhat

• No

18. During your most recent visit, did this provider spend enough time with you?

• Yes, definitely

• Yes, somewhat

• No

19. During your most recent visit, did this provider have the medical information they needed about you?

• Yes, definitely

• Yes, somewhat

• No

20. During your most recent visit, did this provider order a blood test, x-ray, or other test for you?

• Yes

• No Go to Question 22 on page 3

21. Did someone from this provider’s office follow up to give you those results?

• Yes

• No

22. I trust the provider I saw on this visit to give me the care that I need.

• Yes, definitely

• Yes, somewhat

• No

23. Using any number from 0 to 10, where 0 is the worst visit possible and 10 is the best visit possible, what number would you use to rate your most recent visit?

• 0 Worst visit possible

• 1

• 2

• 3

• 4

• 5

• 6

• 7

• 8

• 9

• 10 Best visit possible

STAFF AT PROVIDER’S OFFICE

24. Staff at a provider’s office may talk with you about your visit, help set it up, and remind you about your appointment. Thinking about your most recent visit, did you talk to staff from this provider’s office?

• Yes

• No Go to Question 27

25. Thinking about your most recent visit, was the staff from this provider’s office as helpful as you thought they should be?

• Yes, definitely

• Yes, somewhat

• No

26. Thinking about your most recent visit, did the staff from this provider’s office treat you with courtesy and respect?

• Yes, definitely

• Yes, somewhat

• No

ABOUT YOU

27. In general, I am able to see a provider when needed.

• Strongly Disagree

• Somewhat Disagree

• Neither Agree nor Disagree

• Somewhat Agree

• Strongly Agree

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

• Excellent

• Very good

• Good

• Fair

• Poor

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

• Excellent

• Very good

• Good

• Fair

• Poor

30. 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

31. Please provide any comments about this facility that you would like to share. Please do not provide any personally identifiable information.

_______________________________________________________________________

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THANK YOU FOR TAKING THE TIME TO COMPLETE THE SURVEY!

Your participation in this survey is appreciated and will greatly aid efforts to improve the health of our military community.

Return your survey in the postage-paid envelope.

If the envelope is missing, please send to:

MILITARY HEALTH SYSTEM SURVEY CENTER

c/o Ipsos

P.O. BOX 5030, CHICAGO, IL 60680

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