Hydration Satisfaction of Hines VA CLC Residents

Hydration Satisfaction of Hines VA CLC Residents

OMB No. 2900-0770
Estimated Burden: 4 minutes

Expiration Date: 09/30/2020

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 4 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 survey will lead to improvements in the quality of service delivery by helping to achieve improved Nutrition and Food services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Hydration Satisfaction of Hines VA CLC Residents Survey

OMB No. 2900-0770

Date ______________________________ Unit __________________________

Instructions: Surveyor is to complete questions 1 and 2. Questions 3-14 are to be verbalized to the patient.

TO BE COMPLETED BY SURVEYOR:

1. Prescribed diet:

a. Veteran’s Choice b. Diabetic (Carb Controlled)

c. Regular d. Cardiac

e. Thickened Liquids f. Other ____________________

2. Fluid restriction: YES or NO

RECORD PATIENT’S ANSWERS BELOW:

3. How satisfied are you with the ease of use of the hydration station?

1 - very dissatisfied 2 – dissatisfied 3 - neutral 4 - satisfied 5 - very satisfied

4. If you answered 1-2 on question 3, why are you dissatisfied with the ease of use of the hydration station?

__________________________________________________________________________________________

5. How satisfied are you with the location of the hydration station?

1 - very dissatisfied 2 – dissatisfied 3 - neutral 4 - satisfied 5 - very satisfied

6. If you answered 1-2 on question 5, why are you dissatisfied with the location of the hydration station?

__________________________________________________________________________________________

7. How satisfied are you with how easy it is the use the orange coolers at the hydration station?

1 - very dissatisfied 2 - dissatisfied 3 - neutral 4 - satisfied 5 - very satisfied

8. If you answered 1-2 on question 7, why are you dissatisfied with ease of use of the hydration station?

__________________________________________________________________________________________

9. How satisfied are you with the beverage options, sugar free punch and water, at the hydration station?

1 - very dissatisfied 2 - dissatisfied 3 - neutral 4 – satisfied 5 - very satisfied

10. If you answered 1-2 on question 9, why are you dissatisfied with beverage options at the hydration station? _________________________________________________________________________________________

11. How satisfied are you with the beverage options at your meals?

1 - very dissatisfied 2 - dissatisfied 3 - neutral 4 – satisfied 5 - very satisfied

12. If you answered 1-2 on question 11, why are you dissatisfied with the beverage options on your trays?

_________________________________________________________________________________________

13. How satisfied are you with the coffee station?

1 - very dissatisfied 2 - dissatisfied 3 - neutral 4 – satisfied 5 - very satisfied

14. If you answered 1-2 on question 13, why are you dissatisfied with the coffee station?

__________________________________________________________________________________________