DA Form 3611-r Food Service Division-Patient Satisfaction Survey (Lra)

DA Form 3611-r - also known as the "Food Service Division-patient Satisfaction Survey (lra)" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 3611-r - was last revised on June 1, 1970. Download an up-to-date fillable PDF version of the DA 3611-r below or request a copy through the chain of command.

ADVERTISEMENT
FOOD SERVICE DIVISION - PATIENT SATISFACTION SURVEY
(For use of this form see TM 8-504; the proponent agency is the Office of The Surgeon General)
In order to assist the Food Service Division in giving you satisfactory meals and service,
please check "YES" or "NO" to the following questions. If you wish to make additional
comments or remarks, please use the space provided for this purpose.
YES
NO
1.
Are you on a diet which permits you to read the menu in advance and to select the
size portions that you desire?
2.
Are the heated food items hot enough for you?
3.
Are the chilled food items cold enough for you?
4.
Have all of your favorite foods been served? If answer is no, please list the
food items.
5.
Have you other suggestions for improving the preparation and serving of food?
If your answer is yes, please list your suggestions.
COMMENTS AND REMARKS
DA FORM 3611-R, 1 JUN 1970
APD LC v1.00
FOOD SERVICE DIVISION - PATIENT SATISFACTION SURVEY
(For use of this form see TM 8-504; the proponent agency is the Office of The Surgeon General)
In order to assist the Food Service Division in giving you satisfactory meals and service,
please check "YES" or "NO" to the following questions. If you wish to make additional
comments or remarks, please use the space provided for this purpose.
YES
NO
1.
Are you on a diet which permits you to read the menu in advance and to select the
size portions that you desire?
2.
Are the heated food items hot enough for you?
3.
Are the chilled food items cold enough for you?
4.
Have all of your favorite foods been served? If answer is no, please list the
food items.
5.
Have you other suggestions for improving the preparation and serving of food?
If your answer is yes, please list your suggestions.
COMMENTS AND REMARKS
DA FORM 3611-R, 1 JUN 1970
APD LC v1.00
ADVERTISEMENT