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

What Is DA Form 3611-r?

This is a military form that was released by the U.S. Department of the Army (DA) on June 1, 1970. The form, often mistakenly referred to as the DD Form 3611-r, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 1-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
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Download an up-to-date fillable DA Form 3611-r down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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

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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