Form 10-0526 Caribean Harvey Survey

OMB Number 2900-0770

Estimated Burden: 5 mins

Expiration Date: XX/XX/2014

OPA

PATIENT SATISFACTION SURVEY

OMB 2900-0770

Estimated burden: 5 minutes

Expiration Date xx/xx/xxxx

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 five (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 services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VA Form 10-10128

Pathology and Laboratory Medicine Service Today's date:

Patient Satisfaction Survey – Laboratory __/__/__

We welcome your feedback! Please rate our staff and operation on your experience today!
1. Which location did you visit today for your laboratory procedure?
	San Juan		Arecibo		Ceiba		Guayama
2. Cleanness and comfort of the waiting area.
	Excellent		Acceptable		Needs		Does not Apply
					Improvement
3. How respectful and courteous were the laboratory staffs?
	Excellent		Acceptable		Needs		Does not Apply
					Improvement
4. Are you satisfied with the phlebotomy procedure?
	Excellent		Acceptable		Needs		Does not Apply
					Improvement
5. How long did you wait before your procedure started?
	< 30 min		30-60 min		1-2 hrs.		2-3 hrs.		>3 hrs.
6. How you would rate your overall experience in the laboratory?
	Excellent		Acceptable		Needs		Does not Apply
					Improvement
7. If there is any way we can improve our service to you, please tell us about it:
8. Some information about you:
	Gender			Your age			Are you
	Male			<20			A new patient
	Female			20-30			A returning patient
				31-40
				41-50

Pathology and Laboratory Medicine Service Fecha:

Encuesta de Satisfacción al Paciente - Laboratorio __/__/__

¡Su opinión es muy importante para nosotros!

Por favor evalué nuestras operaciones y al personal del laboratorio basado en sus experiencia del día de hoy!
1. ¿En cual localización o área usted visito hoy para sus procedimiento de laboratorio?
	San Juan		Arecibo		Ceiba		Guayama
2. ¿Como usted evaluaría la comodidad y limpieza en la sala de espera?
	Excelente		Aceptable		Necesita		No Aplica
					mejoría
3. ¿Como usted evaluaría el procedimiento de flebotomía?
	Excelente		Aceptable		Necesita		No Aplica
					mejoría
4. ¿Esta usted satisfecho con el procedimiento de flebotomía?
	Excelente		Aceptable		Necesita		No Aplica
					mejoría
5. ¿Cuanto tiempo usted espero antes de ser atendido para su procedimiento de flebotomía?
	< 30 min		30-60 min		1-2 hrs		2-3 hrs		>3 hrs
6. ¿Como usted en general evalúa su experiencia en el laboratorio?
	Excelente		Aceptable		Necesita		No Aplica
					mejoría
7. En pocas palabras, podría hacernos un comentario o sugerencia para mejorar nuestros servicios:
8. Información sobre usted:
	Género			Su edad			Es usted
	Masculino			<20			Paciente nuevo
	Femenino			20-30			Paciente recurrente
				31-40
				41-50
				51-60
				>60