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pdfOMB 2900-0770
Estimated Burden: 15 minutes
Department of Veterans Affairs
Oklahoma City VA Medical Center
921 NE 13th Street
Oklahoma City, OK 73104
Tel: (405)-456-5139
Dental (Ambulatory) Patient Satisfaction Survey
The Dental Clinic from the Veterans Hospital has the mission to offer our veterans an
excellent health service.
One of the most efficient ways to measure our excellence in patient care and
management is to know your opinion. In order for us to evaluate if we have achieved our
expectations in service, we invite you to answer this survey.
Your response will help us to identify the areas that are working well, that way we can
assure to continue doing it well. We want to identify those healthcare service areas in the
Dental Clinic where we can provide better service.
We like to mention, all information is considered strictly private, to the extent permitted by
law, and will not affect any of the services that you are receiving in the VA hospital.
Please answer all the questions and choose the one that best describe your experience.
Fold and give the survey to the receptionist
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with
the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. 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. Respondents should be aware that notwithstanding any other provision of law, no person
shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid
OMB control number. Customer satisfaction surveys are 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 shape the direction and focus of specific, programs and services. Submission of this form is
voluntary and failure to respond will have no impact on benefits to which you may be entitled.
VA Form
August 2013
10-211008
OMB 2900-0770
Estimated Burden: 15 minutes
Date of your visit:
Hour:
_
Age:
Sex: o M o F
In general, how would you classify the courtesy of the person (s) that attended you in your visit?
Excellent
Good
Regular
Poor
Does not apply
Receptionist
Dental Auxiliaries
Dentists
1. The waiting time between the date you first requested service and the date you were given the service
was:
2. How would you classify the waiting room contort?
3. If you have a physical handicap, facilities available were:
4 Your participation in decision taking in reference of the dental healthcare service you requested was
5. When you asked questions, the answer received were.....
6. The information offered regarding whom to call in case you need help or to clarify any doubts after your
visit were...
7. The privacy offered by your provider, when he attended you was.....
8. When you have requested dental services by telephone, How would you classify the courtesy of the
personnel (whom attended your call)?
9. The dental care received during your visit was....
10. The dental care in Veteran Administration compared with other similar dental services given in other
places was....
11. The date of your appointment you arrived......
On time
Very early (more than an hour before)
Early(less than an hour before)
Late, why
12. The waiting to be seen was:
At time of appointment
Earlier than appointment time
I was seen 10 minutes after appointment time
I was seen 20 minutes after appointment time
I was seen 30 minutes after appointment time
VA Form
August 2013
10-211008
_
| File Type | application/pdf |
| File Modified | 2013-09-12 |
| File Created | 2013-09-12 |