Form VA Form 10-5387 VA Form 10-5387 Customer Satisfaction Survey for Nutrition and Food Serv

OMB Number: 2900-0227
Estimated Burden: 2 minutes

Customer Satisfaction Survey for
Nutrition and Food Service

Good Nutrition . . . . America's Healthy Choice

DEPARTMENT OF VETERANS AFFAIRS
VA FORM
AUG 2006 (RS)

10-5387

DO NOT USE PREVIOUS EDITIONS.

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 this Act. 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 must complete this form
will average 2 minutes. This includes the time it will take to read instructions, gather the necessary facts
and fill out the form. The purpose of this data collection is to determine the level of patient satisfaction
and quality of service resulting from advanced food preparation and advanced food delivery systems.
Response to this survey is voluntary and failure to participate will not effect any benefits to which you
may be entitled.

CUSTOMER SATISFACTION SURVEY FOR NUTRITION / FOOD SERVICES
NAME (Optional)

PATIENT'S UNIT

STATUS (Check One)
INPATIENT

Please rate the food services received during your stay:

AGE (Optional)

TYPE OF DIET
OUTPATIENT

EXCELLENT

VERY GOOD

GOOD

FAIR

UNACCEPTABLE

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

6. Politeness of food service employees.

5

4

3

2

1

7. Food service staff response to my food likes and dislikes.

5

4

3

2

1

Daily meals served in timely manner - about the same
time each day.

5

4

3

2

1

5

4

3

2

1

EXCELLENT

VERY GOOD

GOOD

FAIR

UNACCEPTABLE

5

4

3

2

1

1. Appearance of my meal trays.
2. Taste of the food served.
3. Meals served included foods I like.
4.

Food temperatures of hot foods such as soups, entrees and
coffee.

5.

Food temperatures of cold foods such as juice, milk and
desserts.

8.

9. Time allowed to eat my meals.
10. Overall, I rate the quality of the nutrition/food services
during my hospital stay as:
COMMENTS

VA FORM
AUG 2006 (RS)

10-5387