Form VA Form 10-211001N VA Form 10-211001N Patient Satisfaction Survey_Boston VAMC_Dept. of Ophtham

OMB 2900-0770
Estimated Burden: 15 minutes

PATIENT SATISFACTION SURVEY
Boston VA Medical Center-Jamaica Plain Campus
Department of Ophthalmology
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 15 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. This collection of information is
intended to fulfill the need identified by the Department of Veterans Affairs in their call for the development of needed improvements to the current
Ophthalmology program. Your obligation to respond to this survey is voluntary and failure to furnish this information will have no effect on any of your benefits.

Please CIRCLE one number on each line.
How strongly do you AGREE or DISAGREE with each of the following statements?
Strongly
Agree

Agree

Uncertain

Disagree

Strongly
Disagree

I am satisfied with my office
visit today.

1

2

3

4

5

The time I spent at clinic was
reasonable

1

2

3

4

5

1

2

3

4

5

1. Doctors need to be more
thorough in treating and
examining me.

1

2

3

4

5

2. I am very satisfied with
the medical care I
receive.

1

2

3

4

5

1

2

3

4

5

4. I usually kept waiting long
time before been seen by
the doctor

1

2

3

4

5

5. Sometimes doctors make
me wonder if their
diagnosis is correct.

1

2

3

4

5

1

2

3

4

5

7. The doctors who treat me
have a genuine interest
in me as a person.

1

2

3

4

5

8. Sometimes doctors use
medical terms without
explaining what they
mean.

1

2

3

4

5

I was in clinic ________ Hrs
Please provide the number
of hours.
My travel to and from my
appointment is reasonable.

3. I am usually kept waiting
a long time in the clinic.

6. During my visits I am
always allowed to say
everything that I think is
important.

VA Form
APR 2013

10-211001NR

Please turn over the page

1

Strongly
Agree

Agree

Uncertain

Disagree

Strongly
Disagree

1

2

3

4

5

1

2

3

4

5

12. Sometimes the doctors
hurry too much when
they treat me.

1

2

3

4

5

13. My doctors treat me in a
very friendly and
courteous manner.

1

2

3

4

5

14. Some of the doctors I
have seen lack
experience with my
medical problems.

1

2

3

4

5

15. Doctors sometimes
ignore what I tell them.

1

2

3

4

5

16. Doctors usually spend
plenty of time with me.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

19. Doctors always do their
best to keep me from
worrying.

1

2

3

4

5

20. My doctors are very
competent and well
trained.

1

2

3

4

5

9. There are some things
about the medical care I
receive that could be
better.
10. Explain what can be
done to
improve___________
11. Every time I came I see
the same doctors.

17. I have some doubts
about the ability of the
doctors who treat me.
18. Doctors listen carefully to
what I say.

Please provide any other comments about your care.

When you have completed the form, please return it to the clerical staff as you
check-out for your appointment.

VA Form 10-211001NR
APR 2013