Formic Web Forms - [1 FFT Inpatient Childrens April 2020 Web Form

1 FFT Inpatient Childrens April 2020 Web Form

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

V1-2020

Equality Monitoring

Thinking about your recent stay in hospital...

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

Date of feedback:

If yes, please state:

Ward:

I am answering this as...

Patient

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

Are you male or female?

Female

Prefer not to say

Male

Prefer to use my
own term

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

What is your ethnic group?

Black

White

Asian

Prefer not
to say

Mixed

Other

What is your age?

16+

Under 12 Months

1-5

6-10

11-15

Do you have a disability?

Prefer not to say

Yes

Overall, what was your experience of our service?

Neither
Good
nor Poor

Don't
Know

Very
Poor

Very
Good

Poor

Good

Office Use Only

3 CRH - Childrens Inpatients

3 PAA CRH - Paediatric Assessment Area

4 HRI - Childrens Inpatients

NICU/SCBU - Special Baby/ Neonatal Unit