Form 10-10122 HME Vendor Performance Survey

OMB No. 2900-0770

Estimated Burden: 2.5 Minutes

OMB Expiration Date: XX/XX/XXXX

VISN 12 Home Medical Equipment

Patient Satisfaction Survey

VA Form 10-10122

The Paperwork Reduction Act of 1995: 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 survey will average 2.5 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve improved mental health services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may currently be receiving.

V ISN 12 HOME MEDICAL EQUIPMENT

PATIENT SATISFACTION SURVEY

Veteran’s Name (optional): _____________________________________________________

Item Delivered ________________________________________________________________

Delivery Date_________________________________________________________________

Questions to ask Veteran:

1. Was the equipment delivered within 3 business days from the time the

vendor contacted you? Yes No Yes No

2) Was the delivery technician courteous? Yes No

3) Did the technician call to schedule an appointment before delivering

your equipment? Yes No Yes No

4) Was appointment time kept? Yes No Yes No

5) Were you instructed in how to use the equipment? Yes No

6) Do you understand how to use the equipment? Yes No Yes No

7) Were you given an opportunity to ask questions about the

equipment? Yes No Yes No

8) Do you know the phone number to call if something goes wrong

with the equipment? (If answer is “No,” provide patient the number

to Prosthetics.) Yes No

Any questions or concerns?

Explanation: