VA Form 10-1465-5 SHEP PCMH Short Form 10-1465-5

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

SURVEY OF HEALTHCARE
EXPERIENCES OF PATIENTS
AMBULATORY CARE 2013
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.
We want to remind you that all information is strictly anonymous. It will not be shared with
your doctor or affect your VA care.
Your Privacy is Protected. All information that would let someone identify you or your family will be
kept private. Synovate will not share your personal information with anyone without your OK. Your
responses to this survey are also completely confidential.
Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to,
this will not affect the health care you get.
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 10 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: 43 – 0413

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 PROVIDER
1. Our records show that you got care
from the provider named below in
the last 12 months.
[CLINICIAN NAME]

YOUR CARE FROM THIS PROVIDER
IN THE LAST 12 MONTHS
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.

Is that right?




Yes
NoIf No, go to #44

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?




Yes
No

3. How long have you been going to
this provider?




Less than 6 months



At least 1 year but less than
3 years



At least 3 years but less than
5 years



5 years or more

At least 6 months but less than
1 year

4. In the last 12 months, how many
times did you visit this provider to
get care for yourself?









None If None, go to #44
1 time
2
3
4
5 to 9
10 or more times

5. In the last 12 months, did you
phone this provider’s office to get
an appointment for an illness, injury
or condition that needed care right
away?




Yes
NoIf No, go to #8

6. In the last 12 months, when you
phoned 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?






Never
Sometimes
Usually
Always

7. In the last 12 months, how many
days did you usually have to wait
for an appointment when you
needed care right away?







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

8. In the last 12 months, did you make
any appointments for a check-up or
routine care with this provider?




Yes
No If No, go to #10

9. In the last 12 months, when you
made an appointment for a checkup or routine care with this
provider, how often did you get an
appointment as soon as you
needed?






Never
Sometimes
Usually
Always

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




Yes
No

11. In the last 12 months, did you need
care for yourself during evenings,
weekends, or holidays?




Yes
No If No, go to #13

12. In the last 12 months, how often
were you able to get the care you
needed from this provider’s office
during evenings, weekends, or
holidays?






Never
Sometimes
Usually
Always

13. In the last 12 months, did you
phone this provider’s office with a
medical question during regular
office hours?




Yes
No If No, go to #15

14. In the last 12 months, when you
phoned this provider’s office during
regular office hours, how often did
you get an answer to your medical
question that same day?






Never
Sometimes
Usually
Always

15. In the last 12 months, did you
phone this provider’s office with a
medical question after regular office
hours?




Yes
No If No, go to #17

16. In the last 12 months, when you
phoned 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
Sometimes
Usually
Always

17. Some offices remind patients
between visits about tests,
treatment or appointments. In the
last 12 months, did you get any
reminders from this provider’s
office between visits?




Yes
No

18. Wait time includes time spent in the
waiting room and exam room. In the
last 12 months, how often did you
see this provider within 15 minutes
of your appointment time?






Never
Sometimes
Usually
Always

19. In the last 12 months, how often did
this provider explain things in a way
that was easy to understand?






Never
Sometimes
Usually
Always

20. In the last 12 months, how often did
this provider listen carefully to you?






Never
Sometimes
Usually
Always

21. In the last 12 months, did you talk
with this provider about any health
questions or concerns?




Yes
No If No, go to #23

22. In the last 12 months, how often did
this provider give you easy to
understand information about these
health questions or concerns?






Never
Sometimes
Usually
Always

23. In the last 12 months, how often did
this provider seem to know the
important information about your
medical history?






Never
Sometimes
Usually
Always

24. In the last 12 months, how often did
this provider show respect for what
you had to say?






Never
Sometimes
Usually
Always

25. In the last 12 months, how often did
this provider spend enough time
with you?






Never
Sometimes
Usually
Always

26. In the last 12 months, did this
provider order a blood test, x-ray, or
other test for you?




Yes
No If No, go to #28

27. In the last 12 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?






Never
Sometimes
Usually
Always

28. In the last 12 months, did you and
this provider talk about starting or
stopping a prescription medicine?




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?






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?






Not at all
A little
Some
A lot

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

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?













0

Worst provider possible

1
2
3
4
5
6
7
8
10 Best provider possible

Yes
No If No, go to #35

34. In the last 12 months, how often did
the provider named in Question 1
seem informed and up-to-date
about the care you got from
specialists?






35. In the last 12 months, did anyone in
this provider’s office talk with you
about specific goals for your
health?




Yes
No

36. In the last 12 months, did anyone in
this provider’s office ask you if
there are things that make it hard
for you to take care of your health?




Yes
No

9

33. 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 12
months, did you see a specialist for
a particular health problem?




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

Never
Sometimes
Usually
Always

37. In the last 12 months, did you take
any prescription medicine?




Yes
No If No, go to #39

38. In the last 12 months, did you and
anyone in this provider’s office
talk at each visit about all the
prescription medicines you were
taking?




Yes
No

39. In the last 12 months, did anyone in
this provider’s office ask you if
there was a period of time when you
felt sad, empty or depressed?




Yes
No

40. In the last 12 months, did you and
anyone in this provider’s office talk
about things in your life that worry
you or cause you stress?




Yes
No

41. In the last 12 months, did you and
anyone in this provider’s office talk
about a personal problem, family
problem, alcohol use, drug use, or a
mental or emotional illness?




Yes
No

CLERKS AND RECEPTIONISTS AT
THIS PROVIDER’S OFFICE
42. In the last 12 months, how often
were clerks and receptionists at this
provider’s office as helpful as you
thought they should be?






Never
Sometimes

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







Always

Never
Sometimes
Usually
Always

Excellent
Very Good
Good
Fair
Poor

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







Excellent
Very Good
Good
Fair
Poor

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




Usually

43. In the last 12 months, how often did
clerks and receptionists at this
provider’s office treat you with
courtesy and respect?






ABOUT YOU






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

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




Yes, Hispanic or Latino
No, Not Hispanic or Latino

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







White




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

49. What language do you mainly speak
at home?








50. Did someone help you complete
this survey?

English
Spanish
Chinese
Russian

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

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






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

Vietnamese
Some other language (please
print):
__________________________

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. Health Care 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. Simply place the envelope in any mailbox and return the survey to:
Department of Veterans Affairs
c/o Synovate
P.O. Box 806046
Chicago, IL 60680