1. Do you use a VA facility for your primary health care or mental health care needs? Please mark all that apply.
2. If you use the VA for any of your health care needs, which facility do you visit most often?
3. Have you attempted to make an appointment for health care services at a VA health care facility in the last 24 months? Yes No
4. Were you able to obtain a health care appointment? Yes No N/A
5. Was the health care appointment for:
6.In the last 24 months, if you attended your VA health care appointment, how much time did the provider spend with you?
7. In your opinion, was the time allotted for your appointment appropriate to address your health care needs? Yes No Unsure N/A
8. Including mental health, how many times per year on average do you have a health appointment at a VA facility?
9. Have you had to travel to a VA healthcare facility outside of your area within the last three years for treatment because the service was not available locally? Yes No
10.How would you rate your overall level of satisfaction with the care provided at your primary VA clinic?
11. How would you rate your overall level of satisfaction with your current VA medical facilities?
12. Which of the following is most important to you with regard to your current primary VA facility?(Chose 1)
13. Do you currently have health insurance aside from the coverage provided by the VA? Yes No Unsure
14. How many days went by between your most recent request for a VA appointment and seeing a health care provider?
15. For your most recent health care appointment, how many times did the VA have to cancel or reschedule it? Please indicate a number. Enter “0” if appointment was never cancelled or rescheduled.
16. If you received health care services at your local VA, what was the quality of care? Chose using a scale of 0 to 10, with 0 being the lowest and 10, the highest
17. What year were you born?(YYYY format):
18. How many years since you were discharged from the military?
19. OPTIONAL: Any information or comments regarding the access and quality of healthcare at the VA, that you’d like to add (Limit 500 characters)?
THANK YOU FOR YOUR RESPONSES AND FOR YOUR SERVICE.
