Form VA Form 10-0498 VA Form 10-0498 Food and Nutrition Satisfaction Survey

OMB 2900-0770
Estimated Burden: 2 min.

Nutrition & Food Services
Satisfaction Survey
“Because We Care”
The Paperwork Reduction Act of 1995 requires us to notify you that
this information collection is in accordance with the clearance
requirements of section 3507 of this Act. We may not conduct or
sponsor, and you are not required to respond to, a collection of
information unless it displays a valid OMB number. We anticipate
that the time expended by all individuals who must complete this
form will average 2 minutes. This includes the time it will take to
read instructions, gather the necessary facts and fill out the form.
The purpose of this data collection is to determine the level of
patient satisfaction and quality of service. Response to this survey is
voluntary and failure to participate will not affect any benefits to
which you may be entitled.

Great Nutrition……….America’s Healthy Choice
VA Form 10-0498
NOV 2012

Nutrition & Food
Services

My meals taste good.

Strongly
Agree

Agree

5

4

5

My meals look good.

5

My meals offer variety.

5

Cold food is served cold enough.

5

Hot food is served hot enough.

5

My meals are served in a timely manner.

5

Nutrition employees are polite and courteous.

5

I understand my prescribed diet.

My overall rating of Nutrition and Food Services is
excellent.

5

Comments or Suggestions?
(optional information)

Name:

Room#

4
4
4
4
4
4
4
4

Strongly
Neutral Disagree Disagree

3

2

1

3

2

1

3
3
3
3
3
3
3

2
2
2
2
2
2
2

1
1
1
1
1
1
1