DA Form 3611-R: Patient Satisfaction Survey PDF Download – This simple yet important one-page form helps U.S. Army medical facilities gather direct feedback from patients about hospital food service quality. It supports continuous improvement in meal service for service members, veterans, and their families receiving care at military treatment facilities.
Download the Official DA Form 3611-R PDF Here: https://armypubs.army.mil/pub/eforms/DR_a/pdf/A3611_R.pdf
What Is DA Form 3611-R?
DA Form 3611-R, titled Food Service Division – Patient Satisfaction Survey (LRA), is an official U.S. Army form released on June 1, 1970. The proponent agency is the Office of The Surgeon General, and it is referenced for use under TM 8-504.
“LRA” stands for Local Reproduction Authorized, meaning authorized personnel can reproduce the form as needed within Army channels. It remains available through official Army Publishing Directorate channels and is used in military hospitals and medical centers to assess patient experiences with meals and food service.
Purpose of the Patient Satisfaction Survey
The primary goal of DA Form 3611-R is to help the Food Service Division deliver satisfactory meals and service. Patients answer simple Yes/No questions and provide optional comments or suggestions. This feedback allows food service teams to:
- Identify issues with food temperature, variety, and preparation.
- Improve menu options and portion control.
- Address specific patient preferences and dietary needs.
- Enhance overall patient satisfaction during hospital stays.
Patient feedback plays a key role in military healthcare quality improvement, similar to broader Military Health System (MHS) patient satisfaction initiatives.
How to Complete DA Form 3611-R?
The form is straightforward and designed for quick completion by patients. Key sections include:
- Diet and Menu Selection — “Are you on a diet which permits you to read the menu in advance and to select the size portions that you desire?”
- Food Temperature — Questions on whether heated items are hot enough and chilled items are cold enough.
- Food Variety — “Have all of your favorite foods been served?” (If no, patients list missing items.)
- Improvement Suggestions — Space for ideas on preparation and serving.
- General Comments and Remarks — Open area for additional feedback.
Patients simply check YES or NO boxes and write in the provided spaces. The form typically takes just a couple of minutes.
Who Uses DA Form 3611-R?
This form is primarily used in U.S. Army medical treatment facilities, including hospitals like Brooke Army Medical Center and other installations. It targets patients receiving inpatient care where Food Service Divisions manage meal preparation and delivery.
It supports Army healthcare standards by ensuring meals meet nutritional, safety, and palatability requirements while aligning with broader Tri-Service food safety and quality guidelines.
Why Patient Feedback Matters in Military Hospitals?
Hospital food significantly impacts recovery, morale, and overall patient experience. Studies on military and hospital food services consistently show that factors like temperature, taste, variety, and service attitude strongly influence satisfaction levels.
By using tools like DA Form 3611-R, Army food service teams can:
- Maintain high standards in therapeutic diets.
- Respond quickly to recurring issues.
- Support patient-centered care in military medical environments.
Positive feedback also helps recognize excellent performance by food service staff.
Where to Download and Access the Form?
- Official Source: Army Publishing Directorate — DA Form 3611-R PDF.
- The form is available as a fillable or printable PDF for authorized use.
Always use the latest version from armypubs.army.mil for official purposes.
Related Resources for Army Food Service and Patient Care
For more information on military hospital operations, check resources on the Military Health System patient satisfaction surveys or local medical facility nutrition services. Food service in Army medicine follows strict guidelines to ensure safety, quality, and support for recovery.
Note: This article is for informational purposes and refers to publicly available official forms. For specific guidance on form usage, consult your unit’s food service or medical personnel.
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