Feedback - Friends and Family Test

1/9Select ward, department or area:

2/9The date of your visit:

3/9Thinking about the service we provided, overall, how was your experience of our service?

Selected rating

4/9Please can you tell us why you gave the answer?

5/9Do you feel your views were considered within the decision making process / care plan?

Yes No

6/9Please tell us about anything that we could have done better:

7/9Please rate your overall experience (Poor=1 to Good=10):

8/9Are you pleased or displeased with your experience at the Hospital?

Displeased Neither Pleased

9/9If you wish to, please give us the name(s) of the staff you were particularly pleased or displeased with:

Name(s) of staff

Age - which age group do you belong?

0-18 19-24 25-34 35-44 45-54 55-64 65+ Prefer not to say

Gender - what is your sex?

Male Female Transgender Other Prefer not to say

Ethnicity - what is your ethnic group?

White Mixed/Multiple ethnic groups Asian/Asian British Black/African/Caribbean/Black British Other ethnic group Prefer not to say

Disability - Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? (include any issues/problems related to old age)

Yes, limited a lot Yes, limited a little No disability Prefer not to say

Thinking about your recent visit to the hospital, please tell us about your experience.

Equality and Diversity Monitoring