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

2 FFT AE from April 2020 Web Form

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

Thinking about your recent visit to our A&E deparment...

Equality Monitoring

V1-2020

Date of feedback:

What went well with your care and treatment?

Postcode:

What could we do better?

Site:

If yes, please state:

Overall, how was your experience of our service?

Very
Good

Neither Good
nor Poor

Poor

Very
Poor

Good

Don't
know

What is your sexual orientation?

Heterosexual

Bisexual

Gay-Lesbian

Prefer not to say

Do you have a disability?

Yes

Prefer not to say

Are you male or female?

Male

Female

Prefer not to say

Prefer to use
my own term

Office Use Only

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

I am answering this as a...

Patient

Relative/Carer/Advocate
(please answer the questions below
about the patient)

What is your age?

55-64

45-54

25-34

Prefer not
to say

65-74

16-24

35-44

75+

0-15

What is your ethnic group?

Asian

Other

Prefer not to say

Mixed

White

Black

AandE - Calderdale Royal Hospital

AandE - Huddersfield Royal Infirmary