Formic Web Forms - [5 FFT Community Primary and Secondary Age April 2020

5 FFT Community Primary and Secondary Age April 2020

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

V1-2020

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

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

Equality Monitoring

Thinking about your recent experience of our community service...

Date of feedback:

Which service have
you been seen by?

If yes, please state:

Do you have a disability?

Yes

Prefer not to say

What is your age?

1-5

Under 12 Months

6-10

16+

11-15

Overall, what was your experience of our service?

Very
Poor

Poor

Very
Good

Neither
Good
nor Poor

Good

Don't
Know

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

What is your ethnic group?

White

Other

Black

Mixed

Prefer not
to say

Asian

I am answering this as...

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

Patient

Are you male or female?

Female

Prefer not to say

Male

Prefer to use my
own term

Children's Community Nursing Team

Children's Therapy Physio

Children's Therapy SALT

Children'sTherapy OT

Immunisation Team

Orthotics

Paediatric Dietetics