♦   You should fill out this questionnaire only if you were the patient given this survey. You may need to get help from a family member or friend to answer the questions. That’s okay. 

♦   Answer all the questions by checking the box to the left of your answer.

♦   Your response to this survey is voluntary but will provide us with important information.

♦   You are sometimes told to skip over some questions in this survey. When this happens, you will see an arrow with a note that tells you what question to answer next, like this:

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1. Please identify from which NOSH site you accessed services

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2. Was your most recent stay/visit a:

Please answer the questions about your recent stay at the hospital. Do not include any other hospital stays in your answers.
Your care from nurses

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3. During this hospital stay, how often did nurses treat you with courtesy and respect? (Required.)

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4. During this hospital stay, how often did nurses listen carefully to you? (Required.)

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5. During this hospital stay, how often did nurses explain things in a way you could understand? (Required.)

Your care from doctors

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6. During this hospital stay, how often did doctors treat you with courtesy and respect? (Required.)

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7. During this hospital stay, how often did doctors listen carefully to you? (Required.)

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8. During this hospital stay, how often did doctors explain things in a way you could understand? (Required.)

Your experiences in this hospital

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9. During this hospital stay, did you need medicine for pain?

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10. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

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11. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

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12. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

Overall rating of hospital

Please answer the following questions about your stay at the hospital named on the cover letter. Do not include any other hospital stays in your answers.

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13. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay? (Required.)

0 5 10
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i We adjusted the number you entered based on the slider’s scale.

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14. Would you recommend this hospital to your friends and family? (Required.)

In this next section, we ask several more questions about your stay at the hospital.

During your hospital stay

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15. Were you respected and your preferences considered regarding your treatment and care plan? (Required.)

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16. During this hospital stay, did you have enough say about your treatment? (Required.)

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17. Do you feel that there was good communication about your care between doctors, nurses and other hospital staff? (Required.)

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18. During this hospital stay, did you get all the information you needed about your condition and treatment? (Required.)

Leaving the hospital

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19. Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? (Required.)

Your overall ratings

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20. Overall, do you feel you were helped by your hospital stay? Please answer on a scale where 0 is “not helped at all” and 10 is “helped completely.” (Required.)

0 5 10
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i We adjusted the number you entered based on the slider’s scale.

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21. More information on my rating:

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22. Overall, how was your experience during your hospital stay? Please answer on a scale where 0 is “I had a poor experience” and 10 is “I had a very good experience”. (Required.)

0 5 10
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i We adjusted the number you entered based on the slider’s scale.

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23. More information on my rating:

Your childbirth experience

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24. While in the hospital, did your doctor or nurse answer your questions about your childbirth in a way you could understand?

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25. While in the hospital, did you get enough information about caring for your baby?

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26. While in the hospital, did doctors or nurses respect your wishes for labour and delivery in the care that was provided?

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27. Before you left the hospital, were you given enough information about support services available in your community for you and your baby?

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28. Before you left the hospital, did you get enough information from hospital staff about appointments and tests you and your baby needed after you left the hospital?

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29. Did your prenatal care prepare you for your labour and delivery at the hospital?

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30. Was this your first childbirth experience?

About you

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31. In general, how would you rate your overall physical health? (Required.)

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32. In general, how would you rate your overall mental or emotional health? (Required.)

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33. What is the highest grade or level of school that you have completed? (Required.)

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34. What is your gender? (Required.)

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35. What is your year of birth? Please write in; for example, “1934.”  (Required.)

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36. Was your most recent stay at this hospital for childbirth experience?  (Required.)

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37. The following question will help us to better understand the communities that we serve. Do you consider yourself to be . . . (Required.)

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38. Is there anything else you would like to share about your hospital stay?

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