Nystagmus Network is conducting this survey to understand the experiences people have when they or their child are diagnosed with nystagmus in hospital, and to work with the professionals to improve things if necessary.

If you have more than one experience at a hospital eye department that you would like to tell us about, please fill in the survey as many times as necessary.

ALL QUESTIONS ARE OPTIONAL – if you don’t want us to have your name or other details, please leave them blank. If you do give your details we will respect your privacy.

* 1. Your name

* 2. Name of the person with nystagmus

* 3. Age of the patient with nystagmus at the time of the hospital visit

* 4. Name of the hospital

* 5. Approximate date of the visit

* 6. Type of professional seen, if known

* 7. Please indicate how far you agree with these statements

  Strongly agree Agree somewhat Disagree somewhat Strongly disagree
The person I saw took time to explain how nystagmus was likely to affect my child/me
I got the impression that nystagmus was likely to be a very serious problem
I got the impression that many people with nystagmus cope with it well and have full lives
I felt that the people I spoke to were well-informed about nystagmus
I had the opportunity to ask as many questions as I wanted
I left with a clear idea of how to get more information and help
I was given written information
The written information I was given proved to be helpful and accurate
I was advised against looking for information about nystagmus online

* 8. I was given contact details for

* 9. Is there any way your experience could have been improved? Please give details.

* 10. If you are willing to give us more information or take part in a discussion about this topic, please give your name and contact details below.

Thank you for participating.