Attachment 5.docx
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- Attached to
- NCO 4 West DME Services Federal contract opportunity
- Solicitation number
- 36C24420Q0939
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ATTACHMENT #5
SAMPLE DME SATISFACTION SURVEY VA SIERRA PACIFIC NETWORK
Device/Type of Service (Vendor Name) You have recently received medical equipment 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.
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.
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
2. The equipment and/or supplies were clean when delivered.
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
3. The equipment was set-up so that it operated properly.
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
4. Adequate instructions were given for safe use of the equipment.
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
5. The staff was courteous and helpful.
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
6. After-hour contact numbers were provided?
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
7. I would recommend your service to my friends and family.
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
8. Did the equipment/services you received meet your standards?
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
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:
Name:___________________________________ Phone Number:____________________________
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