OMB No. 2900-0770
Estimated Burden: 2.5 Minutes
OMB Expiration Date: XX/XX/XXXX
VISN 12 Home Medical Equipment
VA Form 10-10122
The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, 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 complete this survey will average 2.5 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve improved mental health services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may currently be receiving.
V
ISN
12 HOME MEDICAL EQUIPMENT
PATIENT SATISFACTION SURVEY
Veteran’s Name (optional): _____________________________________________________
Item Delivered ________________________________________________________________
Delivery Date_________________________________________________________________
Questions to ask Veteran:
Was the equipment delivered within 3 business days from the time the
vendor contacted you? Yes No Yes No
2) Was the delivery technician courteous? Yes No
3) Did the technician call to schedule an appointment before delivering
your equipment? Yes No Yes No
4) Was appointment time kept? Yes No Yes No
5) Were you instructed in how to use the equipment? Yes No
6) Do you understand how to use the equipment? Yes No Yes No
7) Were you given an opportunity to ask questions about the
equipment? Yes No Yes No
8) Do you know the phone number to call if something goes wrong
with the equipment? (If answer is “No,” provide patient the number
to Prosthetics.) Yes No
Any questions or concerns?
Explanation:
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | HOME MEDICAL EQUIPMENT - PATIENT SATISFACTION SURVEY TOOL |
Author | vhamiwohnesj |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |