Health Professional Evaluation Form 2011/12 Survey

This is an annual evaluation available for completion by all health professionals who are currently registered to refer to Cambridge City Council's exercise referral schemes, known as Start-Up and ExSite. Only complete this questionnaire if you refer patients to the City based schemes at Chesterton, the Abbey, Hills Road and Kelsey Kerridge sport centres. Please do not complete this questionnaire if you only send patients to the South Cambridgeshire exercise referral scheme.

Feedback provided by this evaluation may be used to help us improve the level of service offered to you and your patients by these schemes. The questionnaire will take no more than a couple of minutes to complete. Your answers will remain anonymous with regards to identifying specific feedback from a specific person/organisation, in any reports or analysis of the feedback. However, you may wish to provide your contact details if you require a response to any of your comments.

This evaluation is available for completion until Friday 15th June 2012. Thank you for taking the time to complete this questionnaire. It is very much appreciated.

1. What is your occupation?

What is your occupation? Doctor

Physiotherapist

Occupational Therapist

Nurse

Dietitian

Other (please specify)

2. Where do you currently work?

Where do you currently work?

3. Have you made a referral in the last year?

Have you made a referral in the last year? Yes

4. If you have not made a referral, do you have any reasons for not doing this?

If you have not made a referral, do you have any reasons for not doing this?

5. How satisfied are you with:

	Very Satisfied	Satisfied	Neither satisfied or dissatisfied	Dissatisfied	Very dissatisfied	Not applicable
The scheme locations around the City:	*How satisfied are you with: The scheme locations around the City: Very Satisfied	The scheme locations around the City: Satisfied	The scheme locations around the City: Neither satisfied or dissatisfied	The scheme locations around the City: Dissatisfied	The scheme locations around the City: Very dissatisfied	The scheme locations around the City: Not applicable
The patient referral form:	The patient referral form: Very Satisfied	The patient referral form: Satisfied	The patient referral form: Neither satisfied or dissatisfied	The patient referral form: Dissatisfied	The patient referral form: Very dissatisfied	The patient referral form: Not applicable
The health professional registration form:	The health professional registration form: Very Satisfied	The health professional registration form: Satisfied	The health professional registration form: Neither satisfied or dissatisfied	The health professional registration form: Dissatisfied	The health professional registration form: Very dissatisfied	The health professional registration form: Not applicable
Being able to make contact with the exercise referral staff:	Being able to make contact with the exercise referral staff: Very Satisfied	Being able to make contact with the exercise referral staff: Satisfied	Being able to make contact with the exercise referral staff: Neither satisfied or dissatisfied	Being able to make contact with the exercise referral staff: Dissatisfied	Being able to make contact with the exercise referral staff: Very dissatisfied	Being able to make contact with the exercise referral staff: Not applicable
The feedback reports received for clients who complete and don't complete the scheme:	The feedback reports received for clients who complete and don't complete the scheme: Very Satisfied	The feedback reports received for clients who complete and don't complete the scheme: Satisfied	The feedback reports received for clients who complete and don't complete the scheme: Neither satisfied or dissatisfied	The feedback reports received for clients who complete and don't complete the scheme: Dissatisfied	The feedback reports received for clients who complete and don't complete the scheme: Very dissatisfied	The feedback reports received for clients who complete and don't complete the scheme: Not applicable
The exercise referral information on the City Council website:	The exercise referral information on the City Council website: Very Satisfied	The exercise referral information on the City Council website: Satisfied	The exercise referral information on the City Council website: Neither satisfied or dissatisfied	The exercise referral information on the City Council website: Dissatisfied	The exercise referral information on the City Council website: Very dissatisfied	The exercise referral information on the City Council website: Not applicable
The exercise referral scheme overall:	The exercise referral scheme overall: Very Satisfied	The exercise referral scheme overall: Satisfied	The exercise referral scheme overall: Neither satisfied or dissatisfied	The exercise referral scheme overall: Dissatisfied	The exercise referral scheme overall: Very dissatisfied	The exercise referral scheme overall: Not applicable

Please give reasons / explanations for any of your answers in this comment box, if you wish to do so. Thank-you.

6. If you have any specific comments you wish to make about the exercise referral scheme, please use the space below:

If you have any specific comments you wish to make about the exercise referral scheme, please use the space below:

7. OPTIONAL: Please let us know your name and e-mail address if you wish to receive a response to any comments you have made on this survey

OPTIONAL: Please let us know your name and e-mail address if you wish to receive a response to any comments you have made on this survey

Thank you for taking the time to complete this survey. If you require any further information about the exercise referral scheme, please visit: www.cambridge.gov.uk/startup or e-mail: startup@cambridge.gov.uk

Health Professional Evaluation Form 2011/12Exit this survey