Cranford Hospice Service Feedback Form Survey

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* 1. Two things that you found really good:

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* 2. Two things we could improve on:

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* 3. What area in Hawke's Bay are you based in?

North (Napier, Taradale)

South (Hastings, Havelock North)

Central Hawke's Bay

Wairoa District

Other (please specify)

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* 4. What is your relationship with Cranford Hospice?

Patient

Family or whānau

Carer

Healthcare provider

Other (please specify)

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* 5. What services have you had access to? Tick all that apply.

Inpatient Unit

Community / Home visits

Family Support Team: Counsellor, Social Worker, Occupational Therapy, Carer Support, Pastoral Care, Music Therapist

Kaitakawaenga

Other (please specify)

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* 6. From a scale of 1-10 please rate your experience with us on the following:

	Extremely Poor				Average					Excellent	N/A
The care and support we provide	The care and support we provide Extremely Poor	The care and support we provide	The care and support we provide	The care and support we provide	The care and support we provide Average	The care and support we provide	The care and support we provide	The care and support we provide	The care and support we provide	The care and support we provide Excellent	The care and support we provide N/A
The frequency of contact with you	The frequency of contact with you Extremely Poor	The frequency of contact with you	The frequency of contact with you	The frequency of contact with you	The frequency of contact with you Average	The frequency of contact with you	The frequency of contact with you	The frequency of contact with you	The frequency of contact with you	The frequency of contact with you Excellent	The frequency of contact with you N/A
The clarity of information and advice we provide	The clarity of information and advice we provide Extremely Poor	The clarity of information and advice we provide	The clarity of information and advice we provide	The clarity of information and advice we provide	The clarity of information and advice we provide Average	The clarity of information and advice we provide	The clarity of information and advice we provide	The clarity of information and advice we provide	The clarity of information and advice we provide	The clarity of information and advice we provide Excellent	The clarity of information and advice we provide N/A
The support and advice we provide to family and whānau	The support and advice we provide to family and whānau Extremely Poor	The support and advice we provide to family and whānau	The support and advice we provide to family and whānau	The support and advice we provide to family and whānau	The support and advice we provide to family and whānau Average	The support and advice we provide to family and whānau	The support and advice we provide to family and whānau	The support and advice we provide to family and whānau	The support and advice we provide to family and whānau	The support and advice we provide to family and whānau Excellent	The support and advice we provide to family and whānau N/A
The respect we show for your cultural, religious and spiritual needs	The respect we show for your cultural, religious and spiritual needs Extremely Poor	The respect we show for your cultural, religious and spiritual needs	The respect we show for your cultural, religious and spiritual needs	The respect we show for your cultural, religious and spiritual needs	The respect we show for your cultural, religious and spiritual needs Average	The respect we show for your cultural, religious and spiritual needs	The respect we show for your cultural, religious and spiritual needs	The respect we show for your cultural, religious and spiritual needs	The respect we show for your cultural, religious and spiritual needs	The respect we show for your cultural, religious and spiritual needs Excellent	The respect we show for your cultural, religious and spiritual needs N/A

Please share any comments.

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* 7. Please feel free to share your name and contact details so we can thank you for completing this survey.

Name

Address

City/Town

Postal Code

Email Address

Phone Number

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* 8. Would you like us to contact you to discuss any feedback you have in more detail?

Yes

Cranford Hospice Service Feedback Form

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* 1. Two things that you found really good:

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* 2. Two things we could improve on:

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* 3. What area in Hawke's Bay are you based in?

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* 4. What is your relationship with Cranford Hospice?

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* 5. What services have you had access to? Tick all that apply.

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* 6. From a scale of 1-10 please rate your experience with us on the following:

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* 7. Please feel free to share your name and contact details so we can thank you for completing this survey.

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* 8. Would you like us to contact you to discuss any feedback you have in more detail?

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* 9. Any other comments: