Veterans Outcome Assessment
The Veterans' Outcome Assessment (VOA) (Veteran Survey Interview)
VOA_Survey_20141113
Veterans Outcome Assessment
OMB: 2900-0825
OMB
No.
2900-NEW
Estimated
Burden:
30
min.
OMB
Expiration
Date:
XX/XX/XXXX
Veterans Outcomes Assessment VA Form 10-211017
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 30 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve improved mental health services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.
Veterans Outcomes Assessment
Interview Date: Time Started:
Opening text of initial call:
Hello, my name is [Interviewer] and I’m calling from the Department of Veterans Affairs Central Office. I’m trying to reach [Veterans’ name] today. Is he/she available?
[If no, ask if this is the best number to call and for a good time to try to reach him/her.] [If yes, confirm Veteran’s identity by asking for his/her date of birth.]
a) I’m calling today because we’re conducting a survey to help us improve the services that VA offers to you and Veterans like you. We’re asking you to participate because you recently attended a mental health appointment at a VA facility, and your experience can help us understand which programs are helpful to Veterans and how to better meet Veterans’ needs. Congress authorized us to obtain this information in the 2013 National Defense Authorization Act.
I want to emphasize that your participation is completely voluntary, and your decision to participate will have no effect on your entitlement to VHA benefits or the services you receive. The entire survey should take less than 30 minutes including the time it will take for instructions and for you to respond to the questions. We’d like to contact you again in 3 months to see how you are doing at that point and how you feel about the services you have received. Information obtained now and in the follow-up interview in 3 months will allow us to tell program staff how their clients, as a group, are doing in their program and how they feel about the program. We will work with programs to improve in areas where Veterans are reporting problems.
The information that you provide in this survey will be kept confidential and is protected by the Privacy Act of 1974. Your individual responses will not be disclosed to anyone outside VA. In VA reports, the findings will be described for groups of Veterans where individual participants cannot be identified. The exception to these privacy protections is that
we are required to report situations where a Veteran is a danger to self or others. In such cases, we will notify mental health treatment staff or the suicide prevention coordinator at your local VA facility to ensure the necessary support is available.
In order to collect this information VA is required to have a valid OMB Control Number, which is xxx. I can repeat that number if you would like to write it down. Would you like more information about this requirement? [If yes, read Paperwork Reduction Act statement on page 1 of script.]
Do you have any questions?
Would you be willing to answer this survey about yourself and how you’re doing?
3a.
If
no,
continue
with:
VA
staff
want
to
be
sure
that
the
services
they
provide
are
beneficial
for
Veterans
like
you.
It
would
therefore
help
us
to
know
about
your
overall
health,
how
you
are
doing
now,
and
your
experience
with
VA
care.
Can
we
set
up
another
time
to
talk
that
is
convenient
for
you?
What
day
and
time
works
best
for
you?
3b. If still no, discontinue and thank them for their time.
4.
If
yes,
proceed:
If calling a Veteran back for a scheduled assessment:
Confirm Veteran’s identity, as above.
When we spoke recently you said this would be a good time to talk. Would you be willing to answer some questions about yourself and how you’re doing?
If yes, proceed with step 2, as above.
If no, attempt to schedule another time to talk.
If still no, discontinue and thank them for their time.
This interview has three parts covering a variety of topics, all of which can be influenced by effective mental health treatment. First, we have a few questions about your general health and well- being. Then we have some more specific questions about common mental health symptoms and feelings you might be experiencing. Finally, we have a few questions about your experience with VA health care. The possible responses vary between questions, so if you have a pencil and paper to make notes, that might help you keep track.
HRQOL-14
Healthy
Days
Measure—Health
Days Core Module
I’d like to start with 4 questions about your health. The first question is about your health now.
In general, would you say your health is:
Excellent [1]
Very good [2]
Good [3]
Fair [4], or
Poor [5]?
Refused [-99]
I don’t know [-98]
Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
Number of days [0-30]
Refused [-99]
I don’t know [-98]
Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
Number of days [0-30]
Refused [-99]
I don’t know [-98]
During
the past 30
days,
for about
how
many
days did
poor physical or
mental
health keep you
from doing your
usual activities,
such as
work,
recreation, or
self-care, like bathing
yourself,?
Number of days [0-30]
Refused [-99]
I don’t know [-98]
WHO
Disability
Assessment Schedule
2.0 (WHODAS
2.0)
The next four questions ask about difficulties due to health conditions. Health conditions include diseases or illnesses, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and for each question, choose the one answer that best describes how much difficulty you had. Your choices are: None, Mild, Moderate, Severe, and Extreme or cannot do.
In the past 30 days, how much difficulty did you have in:
Learning a new task, for example, learning how to get to a new place?
None [1] __Mild [2] __Moderate [3] __Severe [4]
Refused [-99] I don’t know [-98]
Concentrating on doing something for ten minutes?
None [1] __Mild [2] __Moderate [3] __Severe [4]
Refused [-99] I don’t know [-98]
Dealing with people you do not know?
None [1] __Mild [2] __Moderate [3] __Severe [4]
Refused [-99] I don’t know [-98]
Extreme or cannot do [5]
Extreme or cannot do [5]
Extreme or cannot do [5]
How much have you been emotionally affected by your health problems?
None [1] __Mild [2] __Moderate [3] __Severe [4]
Refused [-99] I don’t know [-98]
Extreme [5]
Kessler
6
Now I have some questions that are specific to your mental health functioning. The following questions ask about how you have been feeling during the past 30 days. Your choices are that you have had this feeling: All of the time, most of the time, some of the time, a little of the time, or none of the time.
During the past 30 days, about how often did you feel…
…nervous?
All of the time [1]
Most of the time [2]
Some of the time [3]
A little of the time [4]
None of the time [5]
Refused [-99]
I don’t know [-98]
…hopeless?
All of the time [1]
Most of the time [2]
Some of the time [3]
A little of the time [4]
None of the time [5]
Refused [-99]
I don’t know [-98]
…restless or fidgety?
All of the time [1]
Most of the time [2]
Some of the time [3]
A little of the time [4]
None of the time [5]
Refused [-99]
I don’t know [-98]
…so depressed that nothing could cheer you up?
All of the time [1]
Most of the time [2]
Some of the time [3]
A little of the time [4]
None of the time [5]
Refused [-99]
I don’t know [-98]
…that everything was an effort?
All of the time [1]
Most of the time [2]
Some of the time [3]
A little of the time [4]
None of the time [5]
Refused [-99]
I don’t know [-98]
…worthless?
All of the time [1]
Most of the time [2]
Some of the time [3]
A little of the time [4]
None of the time [5]
Refused [-99]
I don’t know [-98]
Patient
Health Questionnaire (PHQ-9)
Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself? Here your choices are Not at all, Several days, More than half the days, or Nearly every day.
Not at all [0]
Several days [1]
More than half the days [2]
Nearly every day [3]
Refused [-99]
I don’t know [-98]
[For “Not at all”, interviewer can go directly to question 16.]
[For any response other than “Not at all [0]”] Thank you for letting me know. That concerns me. I’d like to go on with the standard questions, but when we complete the survey, I want to discuss further steps we can take to ensure your safety. Is it okay to come back to that at the end, or would you prefer to do that now?
Brief
Addiction Monitor (BAM)
Now, I have a couple of questions about your alcohol and drug use in the last 30 days.
In the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? One drink is considered one shot of hard liquor (1.5 oz.) or 12- ounce can/bottle of beer or 5 ounce glass of wine.
days Refused [-99] I don’t know [-98]
In the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications? Prescription medications include opiates like Vicodin or sedatives such as Xanax. Please include any medications that were not prescribed to you.
Days Refused [-99] I don’t know [-98]
Veterans
Recovery
Assessment
For the next 5 statements, please respond with how much you disagree or agree with the statement at this point in your life. Indicate whether you strongly disagree, disagree, are not sure, agree, or strongly agree with these statements.
I have my own plan for how to stay or become well.
Strongly disagree [1]
Disagree [2]
Not sure [3]
Agree [4]
Strongly agree [5]
Refused [-99]
I don’t know [-98]
I have goals in life that I want to reach.
Strongly disagree [1]
Disagree [2]
Not sure [3]
Agree [4]
Strongly agree [5]
Refused [-99]
I don’t know [-98]
Coping with my mental illness or emotional problems is no longer the main focus of my life.
Strongly disagree [1]
Disagree [2]
Not sure [3]
Agree [4]
Strongly agree [5]
Refused [-99]
I don’t know [-98]
I have people in the community I can count on.
Strongly disagree [1]
Disagree [2]
Not sure [3]
Agree [4]
Strongly agree [5]
Refused [-99]
I don’t know [-98]
I am encouraged by my mental health providers to take the lead in setting my personal treatment and life goals.
Strongly disagree [1]
Disagree [2]
Not sure [3]
Agree [4]
Strongly agree [5]
Refused [-99]
I don’t know [-98]
Schwartz
Outcomes
Scale-10
(SOS-10)
For the next 10 statements, please respond by indicating the response number that best fits how you have been feeling about your life over the last week. The response numbers range from 0—Never in the last week, to 6—All of the time or nearly all of the time in the last week.
Given my current physical condition, I am satisfied with what I can do.
Never [0] __[1] __[2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
I have confidence in my ability to sustain important relationships.
Never [0] __[1] __[2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
I feel hopeful about my future.
Never [0] __[1] __[2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
I am often interested and excited about things in my life.
Never [0] __[1] [2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
I am able to have fun.
Never [0] __[1] __[2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
I am generally satisfied with my psychological health.
Never [0] __[1] __[2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
I am able to forgive myself for my failures.
Never [0] __[1] __[2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
My life is progressing according to my expectations.
Never [0] __[1] __[2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
I am able to handle conflicts with others.
Never [0] __[1] __[2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
I have peace of mind.
Never [0] __[1] __[2] [3] __[4] __[5] All of the time or nearly all of the time [6]
Refused [-99] I don’t know [-98]
Illness
Management and
Recovery (IMR)
Scales
The next two questions ask about how well you are managing now.
How well do you feel like you are coping with your mental or emotional illness from day to day? The choices are:
Not well at all [1]
Not very well [2]
Alright [3]
Well [4]
Very well [5]
Refused [-99]
I don’t know [-98]
Has your doctors prescribed any medication for you?
If no, select “Not applicable” for Question 34 and skip to next question. If yes, ask Question 34.
How often do you take your medication as prescribed? The choices are
Never [1]
Occasionally [2]
About half of the time [3]
Most of the time [4]
Every day [5]
Not applicable (does not have any prescribed medication) [-97]
Refused [-99]
I don’t know [-98]
Global
Quality of
Life Scale
Please choose any number between 0 and 10 that best describes your overall quality of life. 0 indicates an extremely bad quality of life and 10 indicates a perfect quality of life, so, for example, 5 would be an average quality of life.
Quality of Life (Number between 0 – 10) Refused [-99] I don’t know [-98]
Patient
Global Impression
of Improvement
(PGI-I) Scale
Please choose the response that best describes how your mental health condition is now, compared with how it was before your most recent episode of mental health treatment at the VA. Your choices are:
Very much better [1]
Much better [2]
A little better [3]
No change [4]
A little worse [5]
Much worse [6]
Very much worse [7]
Refused [-99]
I don’t know [-98]
Experience
of Care
and Health Outcomes (ECHO)
Survey
The next 4 questions ask about the counseling or mental health treatment you received from the VA in the last 3 months. The choices are Never, Sometimes, Usually, or Always. Do not include non-VA counseling or mental health treatment.
In the last 3 months, not counting times you needed counseling or treatment right away, how often did you get an appointment for counseling or treatment as soon as you wanted? For this question, do not include treatment received during an overnight stay or self-help groups.
Never [1]
Sometimes [2]
Usually [3]
Always [4]
Refused [-99]
I don’t know [-98]
The next questions are about all the counseling or mental health treatment you got in the last 3 months during office, clinic, and emergency room visits at the VA, as well as over the phone. Do the best you can to include all the different people you went to for counseling or mental health treatment in your answers.
In the last 3 months, how often did the people you went to for counseling or treatment explain things in a way you could understand?
Never [1]
Sometimes [2]
Usually [3]
Always [4]
Refused [-99]
I don’t know [-98]
In the last 3 months, how often did the people you went to for counseling or treatment show respect for what you had to say?
Never [1]
Sometimes [2]
Usually [3]
Always [4]
Refused [-99]
I don’t know [-98]
In the last 3 months, how much were you helped by the counseling or treatment you got? Here the choices are Not at all, A little, Somewhat, or A lot.
Not at all [1]
A little [2]
Somewhat [3]
A lot [4]
Refused [-99]
I don’t know [-98]
In the past 3 months, how sensitive do you feel your mental health care providers were with respect to your race and cultural heritage? Here are the choices are Not at all, A little, Somewhat, or Very sensitive.
Not at all sensitive
A little sensitive
Somewhat sensitive
Very sensitive
Not applicable
Refused [-99]
I don’t know [-98]
I am going to read a list of race and ethnicity groups. Please indicate any of these groups that you consider yourself to be. [Check all that apply.] First, do you consider yourself to be:
Hispanic or Latino?
And do you consider yourself to be:
American Indian or Alaskan Native—[if yes open text field for name of tribe]
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
TCU
Treatment
Engagement—Treatment
Satisfaction
Scale
Now, indicate how strongly you DISAGREE or AGREE with the following statement about the mental health treatment you have received at the VA. Please indicate whether you disagree strongly, disagree, are uncertain, agree, or agree strongly.
You are satisfied with your treatment team.
Disagree Strongly [1]
Disagree [2]
Uncertain [3]
Agree [4]
Agree Strongly [5]
Refused [-99]
I don’t know [-98]
Thinking
about your
current or
most
recent VA
mental health treatment,
is there anything
else you
would like
to tell
me about your
experience?
TEXT BOX
[If item 15 answered anything other than Not at all] Now I’d like to get back to what you said about thoughts that you would be better off dead, or of hurting yourself.
P4
Screener for
Assessing
Suicide Risk
[FOR
PARTICIPANTS
SELECTING
1,2
OR
3
ON
Q42]
[P4Stem] Have you had thoughts about actually hurting yourself?
Yes [1]
No [0]
REFUSED [-99]
I DON’T KNOW [-98]
[If no, proceed with item 16.]
[If yes, refused, or I don’t know, complete following P4 risk assessment.]
[P4PAST] 1. Have you ever attempted to harm yourself in the past?
Yes [1]
No
[0]
REFUSED [-99]
I DON’T KNOW [-98]
[P4PLAN] 2. Have you thought about how you might actually hurt yourself?
Yes [1]
No
[0]
REFUSED [-99]
I DON’T KNOW [-98]
[P4PLANHOW] If Yes, how?
[P4PROB] 3. There’s a big difference between having a thought and acting on a thought. How likely do you think it is that you will act on these thoughts about hurting yourself or ending your life some time over the next month?
Not at all likely [0]
Somewhat
likely [1]
Very
likely
[2]
REFUSED
[-99]
I
DON’T
KNOW
[-98]
[P4PREVENT] 4. Is there anything that would prevent or keep you from harming yourself?
Yes
[0]
No [1]
REFUSED [-99]
I DON’T KNOW [-98]
[P4PREVENTWHAT] If Yes, what?
VETERAN’S
CURRENT
RISK
IS
[P4RISK]
see
chart
below. (transferred
to
end)
RISK CATEGORY |
ITEMS 1 AND 2 |
ITEMS 3 AND 4 |
||||
P4 STEM negative or MINIMAL |
N/A or Neither is highlighted
|
N/A or Neither is highlighted
|
||||
LOWER |
|
At least 1 is highlighted |
|
Neither is highlighted
|
||
|
||||||
HIGHER |
|
At least 1 is highlighted |
|
|
At least 1 is highlighted |
or |
|
-99 or -98 for answer |
|||||
[Results of risk assessment] Minimal Lower Higher
[For those with suicide ideation and “no” response to P4 stem or with minimal risk] You mentioned earlier that you have been thinking about harming yourself. I want to encourage you to talk with your doctor or mental health provider about these thoughts, and I’ll send him or her a message about it. I also want to remind you that the Veterans Crisis Line number is 1-800-273-TALK and is available whenever you might need it.
[For
those
with
suicide
ideation
and
lower
risk]
You
mentioned
earlier
that
you
have
been
thinking
about
harming
yourself
and
have
tried
to
do
so
in
the
past
or
have plans
for how
you
would
do
so
in
the
future.
I
want
to
encourage
you
to
talk
with
your
doctor
or
mental
health
provider
about
these
thoughts.
As
I
mentioned,
I
will
be
notifying
the
Suicide
Prevention
Coordinator
at
your
local
facility
that
you
have
expressed
these
concerns,
and
they
may
contact you to
discuss
them
further.
In
addition,
I
can
transfer
you
to
someone
at
the
Veterans
Crisis
Line so
that
you
can
talk
further
right
now
with
someone
who
is
qualified
to
help
you
in
this
situation.
[If
Veteran
refuses]
I’d
like
to
encourage
you
to
call
the Crisis
Line
whenever you
need
to.
Their
number
is
1-800-273-TALK.
[For
those
with
suicide
ideation
and
higher
risk]
You
mentioned
earlier
that
you
have
been
thinking
about
harming
yourself
and
have
tried
to
do
so
in
the
past
or
have
plans
for
how
you
would
do
so
in
the
future.
As
I
mentioned,
I
will
be
notifying
the
Suicide
Prevention
Coordinator
at
your
local
facility
that
you
have
expressed
these
concerns,
and
they
may
contact
you
to
discuss
these
concerns
further. We’ll
also let
your
mental
health
provider
know
that
you
have
been
having
these
thoughts
about
harming
yourself.
In
addition,
I
can
transfer
you
to
someone
at
the
Veterans
Crisis
Line
so
that
you
can
talk
further
right
now
with
someone
who
is
qualified
to
help
you
in
this situation. [If
Veteran
refuses]
I’d
like
to
encourage
you
to
contact
your
mental
health
provider
and
to
call
the
Crisis
Line
whenever
you
need
to.
Their
number
is
1-800-273-TALK.
Veteran [WARMTRS] a warm transfer to the Veterans Crisis Line.
DECLINED [0]
ACCEPTED [1]
NOT OFFERED [2]
[For those free of suicide ideation and for others after above warm transfer protocol] We’re finished with the survey. I want to thank you very much for taking the time to do this interview and to ask whether we can call you again in about 12 weeks to see how you’re doing?
[If yes] Is this the best number to call? What is the best time of day to reach you? [Establish date/time for follow-up interview]
[If
no]
Would
you
be
willing
to
tell
me
why
you
do
not
want
to
be
called
again
in
12
weeks?
TEXT BOX
Thanks again - the feedback you gave me today will help the VA understand how it can better meet the needs of Veterans like you.
[Complete warm transfer if participant has agreed to it.]
Date completed:
Time completed:
VA
Form
10-211017
XXX
2014
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| File Modified | 0000-00-00 |
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