Formic Web Forms - [2 FFT AE Childrens April 2020 Web Form

2 FFT AE Childrens April 2020 Web Form

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 A&E department...

Equality Monitoring

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

V1-2020

Date of feedback:

If yes, please state:

Site:

I am answering this as...

Patient

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

What is your ethnic group?

Other

White

Mixed

Prefer not
to say

Black

Asian

Do you have a disability?

Prefer not to say

Yes

Are you male or female?

Prefer not to say

Female

Male

Prefer to use my
own term

What is your age?

1-5

Under 12 Months

6-10

16+

11-15

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?

Good

Neither
Good
nor Poor

Very
Good

Poor

Don't
Know

Very
Poor

Office Use Only

Calderdale Royal Hospital

Huddersfield Royal Infirmary