Formic Web Forms - [4 FFT Outpatient Child Development April 2020

4 FFT Outpatient Child Development April 2020

Alternatively you can complete an online form at https://www.cht.nhs.uk/patients-visitors/family-and-friends-test

Please write or draw a picture of your visit. We would also love to hear about what was good and what could be better?

Thinking about your recent visit to our deparment...

Child Development

V1-2020

Tell us what you think about the quality of your care!

Equality Monitoring

Date of feedback:

If yes, please state:

Are you male or female?

Prefer not to say

Male

Prefer to use my
own term

Female

If you DO NOT wish your anonymous
comments to be used in our promotional
material, please tick here:

Overall, what was your experience of our service?

Very
Good

Good

Neither
Good
nor Poor

Don't
Know

Very
Poor

Poor

Do you have a disability?

Prefer not to say

Yes

What is your ethnic group?

Black

Other

Mixed

White

Prefer not
to say

Asian

What is your age?

1-5

6-10

16+

Under 12 Months

11-15

I am answering this as...

Relative/Carer/Advocate
(please answer the questions below
about the child/young person)

Patient