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

O MB Number 2900-0764

Est. Burden: 15 minutes

Expiration Date: 02/28/2025

VA Form 10-10070

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS

Dental Care 2024

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.

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.

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!

*** 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:

Privacy Notice

VA has determined this collection is not subject to the Privacy Act of 1974, and the particular notice and other requirements of the Act do not apply. Specifically, VA will not collect information about individuals and will not use a name or any other personal identifier to routinely retrieve records from the information collected. Your anonymous responses will be used to gauge customer satisfaction, and the results of this survey will lead to improvements in the quality of VA program administration and service delivery. Participation in this survey is voluntary, and your failure to respond will have no impact on any benefits to which you are entitled.

VA Burden Statement

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. The OMB control number for this project is 2900-0764, and it expires 2/28/2025. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing this burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-0764 in any correspondence. Do not send your completed VA Form 10-10070 to this email address.

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 If Yes, go to #1

 No

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

 Yes

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

ABOUT YOUR HEALTH

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

 Excellent

 Very good

 Good

 Fair

 Poor

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

 Excellent

 Very good

 Good

 Fair

 Poor

YOUR REGULAR DENTIST

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

4. Do you have a regular VA dentist?

 Yes

 No If No, go to #11

5. Have you seen your regular VA Dentist in the last 12 months?

 Yes

 NoIf No, go to #11

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

 Never

 Sometimes

 Usually

 Always

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

 Never

 Sometimes

 Usually

 Always

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

 Never

 Sometimes

 Usually

 Always

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

 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?

 0 Worst regular dentist possible

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10 Best regular dentist possible

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?

 Never

 Sometimes

 Usually

 Always

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

 Never

 Sometimes

 Usually

 Always

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

 Never

 Sometimes

 Usually

 Always

14. If you needed to see a dentist right away because of a dental emergency in the 12 months, did you get to see a dentist as soon as you wanted?

 I did not have a dental emergency in the last 12 months

 Definitely yes

 Somewhat yes

 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?

 I did not try to get an appointment with a specialist dentist for myself in the last 12 months

 Never

 Sometimes

 Usually

 Always

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?

 Never  If Never, go to #18

 Sometimes

 Usually

 Always

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?

 Never

 Sometimes

 Usually

 Always

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?

 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 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?

 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?

 Yes

 No If No, go to #23

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?

 Definitely yes

 Somewhat yes

 Somewhat no

 Definitely no

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?

 Definitely yes

 Somewhat yes

 Somewhat no

 Definitely no

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

 Routine cleaning, check-up or examination

 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

 Don’t know / don’t remember

 Other

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?

 Never

 Sometimes

 Usually

 Always

25. How would you rate the following aspects of the dental examination or dental treatment room:

	Poor	Fair	Good	Very Good	Excellent	Does Not Apply
Cleanliness of the room						
Privacy while in the room						
Noise level						
Sense of safety and security						

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

	Poor	Fair	Good	Very Good	Excellent	Does Not Apply
Cleanliness of the reception/waiting area						
Cleanliness of the restroom/lavatory						
Availability of parking						
How would you rate the clinic building overall (i.e. attractiveness of facility appearance, quality of building maintenance and upkeep)?						
In terms of your satisfaction, how would you rate the convenience of the location of the clinic facility?						

DENTAL COVERAGE AND ELIGIBILITY

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

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?

 Never

 Sometimes

 Usually

 Always

ABOUT YOU

28. What is your age?

 18 to 24

 25 to 34

 35 to 44

 45 to 54

 55 to 64

 65 to 74

 75 to 84

 85 or older

29. Are you male or female?

 Male

 Female

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. Are you of Hispanic or Latino origin or descent?

 Yes, Hispanic or Latino

 No, not Hispanic or Latino

 I choose not to answer this question

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

 White

 Black or African-American

 Asian

 Native Hawaiian or other Pacific Islander

 American Indian or Alaska Native

 I choose not to answer this question

33. Did someone help you complete this survey?

 Yes

 No  Thank you. Please return the completed survey in the postage-paid envelope.

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

 Read the questions to me

 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:

_________________________________

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 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