Attachment D.4 - Patient Tray Assessment.pdf

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Attached to
S203--Indy Domiciliary Food Service Open Market VIP Verified SDVOSB Set Aside
Solicitation number
36C25022Q0346
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This document contains a patient tray assessment form and details for a federal contract opportunity for domiciliary food services. The solicitation is for an open market set aside for verified service-disabled veteran-owned small businesses to provide domiciliary food services at the Richard L. Roudebush VA Medical Center in Indianapolis in accordance with the performance work statement. The assessment form is a template for evaluating tray deliveries based on food temperature, flavor, appearance, and resident feedback. It includes spaces to record times for cart departure from the kitchen and arrival at the unit as well as when the first and last trays are served.

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Other files

File Type Posted
36C25022Q0346 0001.docx DOCX document
Attachment D.2 - DOM Catering Contract QASP.pdf PDF
Attachment D.6 - Domiciliary Kitchen Equipment List.pdf PDF
Attachment D.7 - Food Safety and Sanitation Audit.pdf PDF
36C25022Q0346.docx DOCX document
Attachment D.3 - Nutrition _ Food Satisfaction Survey.pdf PDF
Attachment D.5 - VHA Healthy Diet Guidelines.pdf PDF

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U:\Martin\Domiciliary Catering\RFQ\Attachment D.4 - Patient Tray Assessment.doc

Indy VA Test Tray Form Meal: Date: Unit: Domiciliary

Texture of food: Regular_____ Mechanically Altered _____Puree_____

Time cart left kitchen: Time cart arrived at unit: Time first tray served: Time last tray served:

Overall Tray Appearance: ____Acceptable ____Needs Improvement ____ Unacceptable If NI or U why: ________________________

Food Appearance: ____Acceptable ____ Needs Improvement ____ Unacceptable If NI or U why:

Plate Base Heater Temperature: on/off switch only Cold Entree?: Y/N

Food Temperature and Flavor

Menu Item (place dash if item not included)

Temp on Tray Line

(Cooks)

Temp upon Delivery

Food Flavor Acceptable (A), Needs Improvement (NI) Unacceptable (U)

Overall Quality Excellent =5, Very Good=4, Good=3, Fair=2, Unacceptable=1

Evaluator Comments:

Hot Entrée Cold Entrée Starch Hot Vegetable Soup/Hot Cereal Salad Dessert/Fruit Hot Beverage Juice/Cold Bev Milk Standing Order or Other Sides

Resident/patient comments (Talk to 2-3 residents on similar diet):

Evaluator: Elisabeth Hortenberry, RD

Tray not set up properly Incorrect utensils Foods not plated properly Unclean utensils/plate/tray

Notes:

1-Please fill out this form entirely 2-Please attach the tray ticket 3-Return completed form to NFS Administrative Dietitian

File details come from the government source that posted it. Updated .