Attachment C - Customer Satisfaction Survey - Downstate Home Oxygen.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24226R0081
About this file
This is a Customer Satisfaction Survey form designed by the Department of Veterans Affairs, Veterans Health Administration, Veterans Integrated Service Network 2 (VISN 2) to assess contractor performance for home oxygen and respiratory therapy services provided to veterans in the Downstate region. The survey is part of the contract monitoring process for the solicitation 36C24226R0081 covering Downstate Home Oxygen Services.
The survey instrument contains eight rated measures using a five-point scale (Excellent, Average, Poor, with numerical values 5-1) addressing key service delivery aspects: timeliness of equipment and supply delivery, cleanliness of delivered items, equipment functionality, adequacy of safety instructions, staff courtesy and helpfulness, communication regarding after-hours assistance availability, overall service recommendation likelihood, and whether services met patient standards. The form includes an open-ended comments section for safety improvement suggestions and optional contact information for follow-up on problems. Completed surveys are collected by contractors and mailed to Buffalo VAMC, Attention Peter Walsh, for centralized collection and analysis as part of ongoing contract monitoring and performance evaluation.
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Text version
ATTACHMENT C – VISN 2 HOME OXYGEN CUSTOMER SATISFACTION SURVEY
Home Oxygen and Respiratory Therapy Contract Monitoring Department of Veterans Affairs Healthcare Network – Downstate
You have recently received oxygen, respiratory therapy equipment, and a home visit from a Respiratory Therapist contracted by the Department of Veterans Affairs. It is important that we know how you feel about the service you received. Please take a moment to fill out the following questionnaire and return it to us. Thank you for your input.
I receive my VA Services from the following VA Medical Center: ________________________ Please grade us on the following measures of service. Rating Excellent Average Poor 5 4 3 2 1
1. The equipment and/or supplies were delivered at the agreed upon time.
2. The equipment and/or supplies were clean when delivered.
3. The equipment operated properly.
4. Adequate instructions were given for safe use of the equipment.
5. The staff was courteous and helpful.
6. How to contact us for after-hour assistance was explained?
7. I would recommend your service to my friends and family.
8. Did the services you received meet your standards?
Please tell us how we can improve your safety regarding the equipment/therapy you received from our company:
Comments:
OPTIONAL: Please tell us how to contact you if you had a problem and wish to be contacted:
Name:
Phone Number:
HAVE PATIENT FILL OUT AND PUT IN ENVELOPE. COLLECT ENVELOPE AND MAIL TO VA:
Buffalo VAMC, 3495 Bailey Ave, Buffalo, NY 14215 Attention - Peter Walsh
File details come from the government source that posted it. Updated .