ATTACHMENT 5 - PATIENT SATISFACTION SURVEY.docx
DOCX document 22 KB Posted
- Solicitation number
- 36C24427Q0003
About this file
This is a Patient Satisfaction Survey template designed for veterans who have received Durable Medical Equipment (DME) through the Department of Veterans Affairs contracting process. The survey measures contractor performance across eight key service dimensions using a five-point rating scale (Excellent to Poor): timely delivery, equipment cleanliness upon delivery, proper setup and operation, provision of safety instructions, contractor personnel courtesy and helpfulness, availability of after-hours contact numbers, willingness to recommend services to others, and overall equipment and service quality. The form also includes open-ended sections for veterans to provide feedback on safety improvements and additional comments, along with fields to capture veteran contact information, device/service type, contractor name, and whether the veteran consents to follow-up contact regarding their experience. This survey serves as a quality assurance and feedback mechanism for the VA's DME services contract, specifically for VISN 4 East Medical Center operations, and enables contractors to gather performance data directly from end-users to support continuous service improvement and accountability requirements.
View the file
Other files
Show all 18
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .