Form VA Form 10-0548 VA Form 10-0548 Community Living Center (CLC) Satisfaction Survey

OMB 2900-XXXX
Estimated Burden: 10 minutes

Expiration Date: XX/XX/XXXX

Department of Veterans Affairs

Community Living Center (CLC) Resident Satisfaction Survey

Oklahoma City VA Medical Center

PRA Statement: 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 consent form will average 10 minutes. This includes the time it will take to read information provided and gather the necessary facts to fill out the form. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

This is a voluntary survey about your CLC experience. Your ratings help improve our service to you and others. Circle the rating that best describes your satisfaction with the CLC. Feel free to add comments.

1. Facilities – How would you rate the CLC facilities overall?

Does not apply Poor Fair Good Very Good Excellent

Comments_________________________________________________________________

2. Concern and caring by CLC medical providers (doctor, physician assistant, nurse practitioner): Courtesy and respect you were given; friendliness and kindness.

Does not apply Poor Fair Good Very Good Excellent

Comments_________________________________________________________________

3. Nurse Services – Thinking about your CLC stay, how would you rate courtesy and respect shown to you by nurses?

Does not apply Poor Fair Good Very Good Excellent

Comments_________________________________________________________________

4. Physical Therapy – If you saw physical therapy during your CLC stay, how would
you rate the quality of the services you received?

Does not apply Poor Fair Good Very Good Excellent

Comments_________________________________________________________________

5. Occupational Therapy – If you saw occupational therapy during your CLC stay,
how would you rate the quality of services you received?

Does not apply Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

6. Recreation Therapy (OASIS) – If you saw recreation therapy during your CLC stay,
how would you rate the quality of the services you received?

Does not apply Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

7. Social Work: If you saw a social worker during your CLC stay, how would you rate
the quality of the services you received?

Does not apply Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

8. Dietician: If you saw a dietician during your CLC stay, how would you rate the quality
of nutritional care you received?

Does not apply Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

9. Speech Therapy – If you saw speech therapy during your CLC stay, how would you
rate the quality of the services you received?

Does not apply Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

10. Psychology – If you saw psychology during your CLC stay, how would you rate the quality of services you received?

Does not apply Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

11. Psychiatry –In terms of your satisfaction, how would you rate the psychiatry
doctor's explanation of what was done for you?

Does not apply Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

12. Pharmacist – My pharmacist explained things thoroughly.

Does not Strongly Disagree Not Sure Agree Strongly

Apply Disagree Agree

Comments__________________________________________________________________

14. Chaplain – If you saw a Chaplain during your CLC stay, how would you rate the
quality of services you received?

Does not apply Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

15. Thinking about your CLC stay, please rate how well you were helped?

Does not apply Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

16. Please rate your overall sense of safety on the CLC:

Poor Fair Good Very Good Excellent

Comments__________________________________________________________________

17. Please rate the overall quality of care and services on the CLC:

Poor Fair Good Very Good Excellent

18. Thinking about your CLC stay, how well did your CLC stay meet your needs?

Did not meet Partly met Fully met

my needs my needs my needs

Comments_____________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________Name (Optional)___________

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VA Form 10-0548
MAY 2012