Form VA Fform 10-211006 VA Fform 10-211006 Outpatient Pharmacy Customer Satisfaction Survey

OMB 2900-0770
Estimated Burden: 5 min.

Outpatient Pharmacy Customer Satisfaction Survey
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 5
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. Your obligation to respond to this survey is voluntary and failure to furnish this
information will have no effect on any benefits you are entitled.

1. For each part of your VA pharmacy visit, please tell us the amount of improvement needed, if any:
a. The length of time you waited at the VA pharmacy
 No improvement needed
 Slight improvement needed
 Some improvement needed
 A lot of improvement needed
 Does not apply
b. The courtesy of the VA pharmacy staff
 No improvement needed
 Slight improvement needed
 Some improvement needed
 A lot of improvement needed
 Does not apply
c. Personal privacy in the VA pharmacy waiting room
 No improvement needed
 Slight improvement needed
 Some improvement needed
 A lot of improvement needed
 Does not apply
2. Overall, how satisfied were you with pharmacy services provided at the Huntington VA Medical Center,
Pharmacy Outpatient window during the past three months?
 Very dissatisfied
 Somewhat dissatisfied
 Neither satisfied nor dissatisfied
 Somewhat satisfied
 Very satisfied
3. After taking a number, how long did you wait to see a pharmacist?
 0-10 minutes
 11-20 minutes
 21-30 minutes
 31-40 minutes
 Over 40 minutes
 Does not apply. Did not have to see a pharmacist.

VA Form
AUG 2013

10-211006NR

4. After you saw a pharmacist, how long did you wait to pick up your prescription?
 0-10 minutes
 11-20 minutes
 21-30 minutes
 31-40 minutes
 Over 40 minutes
 Does not apply.
5. What is one thing you would you change about your outpatient pharmacy experience?
 Wait time
 Pharmacist counseling booth
 Prescription Pick Up Window
 Waiting area
 Other (please specify)________________________________

VA Form
AUG 2013

10-211006NR