Attachment C - Customer Satisfaction Survey - Downstate Home Oxygen

ATTACHMENT C – VISN 2 HOME OXYGEN CUSTOMER SATISFACTION SURVEY

Home Oxygen and Respiratory Therapy Contract Monitoring Department of Veterans Affairs Healthcare Network – Downstate

You have recently received oxygen, respiratory therapy equipment, and a home visit from a Respiratory Therapist contracted by the Department of Veterans Affairs. It is important that we know how you feel about the service you received. Please take a moment to fill out the following questionnaire and return it to us. Thank you for your input. Please grade us on the following measures of service. Rating Excellent Average Poor

5 4 3 2 1

The equipment and/or supplies were delivered at the agreed upon time. The equipment and/or supplies were clean when delivered. The equipment operated properly.
Adequate instructions were given for safe use of the equipment. The staff was courteous and helpful.
How to contact us for after-hour assistance was explained? I would recommend your service to my friends and family. Did the services you received meet your standards?

Please tell us how we can improve your safety regarding the equipment/therapy you received from our company:

Comments:

OPTIONAL: Please tell us how to contact you if you had a problem and wish to be contacted:

Name:

Phone Number:

HAVE PATIENT FILL OUT AND PUT IN ENVELOPE. COLLECT ENVELOPE AND MAIL TO VA:

Buffalo VAMC, 3495 Bailey Ave, Buffalo, NY 14215
Attention - Peter Walsh