ATTACHMENT 5 - PATIENT SATISFACTION SURVEY.docx
DOCX document 22 KB Posted
- Solicitation number
- 36C24427Q0004
About this file
This is a patient satisfaction survey template designed to collect feedback from veterans receiving durable medical equipment (DME) services through the Department of Veterans Affairs. The survey evaluates contractor performance across eight key service metrics using a five-point scale (Excellent to Poor), including timely delivery, equipment cleanliness, proper setup and operation, safety instructions, contractor courtesy and helpfulness, after-hours contact availability, overall service recommendation likelihood, and whether services met patient standards. The form also includes open-ended sections for patients to provide suggestions for safety improvements and additional comments, along with fields to capture veteran name, contact information, device/service type, contractor name, and consent for follow-up contact regarding their experience.
This attachment serves as a quality assurance and performance monitoring tool for the DME services solicitation (36C24427Q0004) supporting VISN 4 West medical centers under the Department of Veterans Affairs Veterans Health Administration. The survey enables the VA to systematically gather patient-level data on contractor performance and identify areas for service improvement, ensuring that contracted DME providers maintain standards for delivery, installation, instruction, and customer service throughout the supply chain.
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Text version
ATTACHMENT 5
PATIENT SATISFACTION SURVEY
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 measures of service using the following ratings.
Excellent
Average
Poor
Circle a rating that best suits your response.
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 Contractor personnel was courteous and helpful.
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
6. After-hour contact telephone 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 received meet your standards?
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
Please tell us how we can improve your safety regarding the equipment and/or therapy you received from our company:
Additional Comments:
| Veteran Name: |
| Date: |
Veteran Phone:
| Device/Type of Service: |
| Contractor Name: |
Do you wish to be contacted regarding your experience?
(Please check “Yes” or “No”)
| Yes |
| No |
File details come from the government source that posted it. Updated .