Customer Survey form

Please rate the level of the following by ticking the box that best describes your experience

Fields marked with * are required.

Staff

 N/A Poor Average Good Excellent
Friendliness and helpfulness Nurses
Others
Compassion and respect Nurses
Others

Care

 N/A Poor Average Good Excellent
The quality of care you received
Information about your care received

Facilities

 N/A Poor Average Good Excellent
Standard of your accommodation
Standard of cleanliness

Communication and Information

 N/A Poor Average Good Excellent
Information you received before your admission
Yes No
Are you aware of your rights & responsibilities
Are you aware of how to make a complaint

Pastoral Care Services

 Yes No
Have you or your relatives or friends been visited by Pastoral Care Staff or had access to Pastoral Care Services during your stay in Hospital?
If so, do you have any comments regarding your experience of the visits or services?

Would you recommend us to others?

(please tick only one)		 Not likely at all Not very likely Quite likely Good Very likely