* 1. In which ICU did your family receive care?

* 2. What month did your family member receive care in the ICU?

* 3. How often were you satisfied with the availability of the doctor to speak with you on a regular basis?

* 4. How often were you satisfied with the nurse's ability to speak with you every day about your family member's care?

* 5. How often were you provided with clear explanations of the tests, procedures, and treatments?

* 6. How often were you satisfied that you were able to share in decisions regarding your family member's care?

* 7. How often were you satisfied with the support and encouragement given to you during your family member's stay in the ICU?

* 8. How often were you satisfied with the flexibility of the visiting times?

* 9. How often did you find the waiting area peaceful and safe?

* 10. How often were you satisfied with the cleanliness and appearance of the waiting area?

* 11. Using any number from 0-10, where 0 is the worst experience possible and 10 is the best experience possible, what number would you use to rate your overall experience as a family member of a patient in this ICU?

* 12. Comments:

* 13. Would you like to be contacted regarding any of your responses, positive or negative?

* 14. Respondent Name (optional)
Patient Name (optional)
Physician Name (optional)
e-mail (optional)
phone # (optional)

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