Form VA Form 10-10063 VA Form 10-10063 Patient Satisfaction Survey- Radiation Oncology

OMB 2900-0770
Estimated Burden: 5 min.

Patient Satisfaction Survey- Radiation Oncology
THE PAPERWORK REDUCTION ACT OF 1995 requires us to notify you that this information collected is in accordance with the
clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average
5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. No person will be penalized for failing to furnish this
information if it does not display a currently valid OMB control number. Your obligation to respond to this survey is voluntary and failure
to furnish this information will have no effect on any benefits you are entitled.

In a continuing effort to improve our service to you, we ask that you take a few minutes to let us know how
we are doing. Please complete this short survey and return it to the reception area or in the self-addressed
stamped envelope. We greatly value your time and input.
Treatment Room/Procedure Area: ___________________________________________________
Your care providers were: _________________________________________________________
Month of last treatment: ___________________________________________________________
Using the key below, please grade our service by circling the appropriate number in each of the following categories.
1 = Poor
2 = Below Average
3 = Average
4 = Good
5 = Excellent
Office Staff
1. Telephone Politeness
2. Greetings
3. Prompt Attention
4. Pleasant Attitude
5. Assistance with Questions
6. Were you informed about your wait time for registration?
Radiation Therapists
1. Willingness to listen
2. Professionalism of therapists
3. Provided compassionate care?
4. Were you informed of your wait time for treatment?
Nurses
1. Willingness to listen
2. Availability to answer questions
3. Helpfulness in providing me with personal care
instructions during treatment
4. Willingness to accommodate special needs
5. Were you informed of your wait time to see a nurse?
Doctors
1. Willingness to listen
2. Spends an appropriate amount of time with you?
3. Answered your questions completely and thoroughly?
4. Provided professional and compassionate care?
3. Helps you understand your medical condition?
I would recommend OKCVA Radiation Oncology to others?

1
1
1
1
1
Yes

2
2
2
2
2
No

3
3
3
3
3

4
4
4
4
4

5
5
5
5
5

1
1
1
Yes

2
2
2
No

3
3
3

4
4
4

5
5
5

1
1

2
2

3
3

4
4

5
5

1
1
Yes

2
2
No

3
3

4
4

5
5

1
1
1
1
Yes

2
2
2
2
No

3
3
3
3

4
4
4
4

5
5
5
5

Yes

No

Was there a particular staff member that you would like to recognize? Or any other comments for suggestions for
better care:
___________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
VA Form
APR 2013

10-10063