VA form 10-0553 Dental Service Customer Satisfaction Survey

OMB 2900-XXXX

Estimated Burden: 15 minutes

Expiration Date: XX/XX/XXXX

Caribbean Healthcare System

Casia Street #10

San Juan, PR 00921-3201

Tel. 641-7582

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.

Date of your visit: ____________________ Hour: ___________ Age: _________ Sex: M 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 Auxilliaries     

Dentists     

________________________________________________________________________________________________________

1. The waiting time between the date you first requested service and the date you were given the service was:

 Excellent  Poor

 Good  Doesn't Apply  Regular

2. The date of your appointment you arrived…

 On time

 Very early (more than ½ hour before)

 Early (less than ½ hour before)

 Late, why __________________________________

3. The waiting to be seen was :

 At time of appointment

 Earlier than the 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

4. How would you classify the waiting room comfort?

 Excellent  Poor

 Good  N/A

 Fair

5. If you have a physical handicap, facilities available were…

 Excellent  Poor

 Good  N/A

 Fair

6. Your participation in the decision taking in reference of the dental healthcare service you requested was…

 Excellent  Poor

 Good  N/A

 Fair

7. When you asked questions, the answers received were…

 Excellent  Poor

 Good  N/A

 Fair

8. The information offered regarding whom to call in case you need help or to clarify any doubts after your visit were…

 Excellent  Poor

 Good  N/A

 Fair

9. The privacy offered by your provider, when he attended you was…

 Excellent  Poor

 Good  N/A

 Fair

10. When you have requested dental services by telephone, How would you classify the courtesy of the personnel (whom attended your call)?

 Excellent  Poor

 Good  N/A

 Fair

11. The dental care received during your visit was…

 Excellent  Poor

 Good  N/A

 Fair

12. The dental care in the Veterans Administration compared with other similar dental services given in other places was …

 Excellent  Poor

 Good  N/A

 Fair

Comments:

VA Form 10-0553
June 2012