Attachment C - Customer Satisfaction Survey - Upstate Home Oxygen.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C24226R0081
About this file
This is a customer satisfaction survey template designed for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network (VISN) 2 Upstate New York home oxygen and respiratory therapy contract monitoring program. The survey is administered to veterans who have received oxygen, respiratory therapy equipment, and home visits from VA-contracted respiratory therapists to gather feedback on service quality and customer experience.
The survey measures eight key service performance areas using a five-point rating scale (Excellent, Average, Poor, with numerical values 5-1): timeliness of equipment and supply delivery, cleanliness of delivered equipment, proper equipment operation, adequacy of safety instructions, staff courtesy and helpfulness, clarity of after-hours contact procedures, likelihood of service recommendation, and overall service quality against patient standards. The form includes fields for patients to identify their servicing VA Medical Center (Albany, Bath, Canandaigua/Rochester Outpatient Clinic, Syracuse, or Buffalo), provide optional written comments on safety improvements, and voluntarily provide contact information if issues require follow-up. Completed surveys are collected and mailed to the VA facility at 3495 Bailey Ave, Buffalo, NY 14215. This survey instrument is used for contract quality assurance and monitoring of home oxygen services provided under solicitation 36C24226R0081 for VISN 2 Prosthetics Downstate Home Oxygen Services.
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ATTACHMENT 1 – VISN 2 HOME OXYGEN CUSTOMER SATISFACTION SURVEY
Home Oxygen and Respiratory Therapy Contract Monitoring Department of Veterans Affairs Healthcare Network – Upstate New York
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:
Albany Bath Canandaigua/Rochester Outpatient Clinic Syracuse Buffalo 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:
VA / /X, 3495 Bailey Ave, Buffalo, NY 14215
File details come from the government source that posted it. Updated .