ACCESS Patient/Relative Feedback
Thank you for taking the time to answer these questions. All of your feedback is gratefully received and will help us improve the service. This form can be completed by a patient or a relative/carer on behalf of a patient.
You are:
The patient who was transferred
The patient's relative/carer
If you are the patient’s relative/carer filling in this feedback form, did you accompany the patient on the transfer?
Yes
No
If you were given an ACCESS feedback card with a job number, please write it here
Date of the transfer
-
Day
-
Month
Year
Date
Referring (sending) Hospital
Receiving (destination) Hospital
Did you know that the transfer to another hospital was going to take place?
Yes
No
Were you given a reason for the transfer?
Yes
No
If yes, please give the reason:
Were you in any pain on your transfer journey?
No pain at all
1
2
3
4
5
6
7
8
9
Extremely painful
10
1 is No pain at all, 10 is Extremely painful
Were you comfortable on your journey to the other hospital?
Not comfortable
1
2
3
4
5
6
7
8
9
Incredibly comfortable
10
1 is Not comfortable, 10 is Incredibly comfortable
Did the team engage with you during the journey?
Yes
No
Were all your needs met on the transfer?
Yes
No
Did you feel welcomed on arrival at the new hospital?
Yes
No
Please write here any feedback comments you would like to make:
You may remain anonymous, or you can give us your details if you are happy to be contacted about your comments.
I wish to remain anonymous
I am happy to be contacted
Name
First Name
Last Name
Email
example@example.com
Date form
-
Day
-
Month
Year
Date
Hour Minutes
If you wish to remain anonymous please tick the box.
I wish to remain anonymous and not be contacted by ACCESS to provide feedback your comments.
Submit
Should be Empty: