Patient Aftercare Survey

This survey is Private & Confidential, Senior Management of Codeblue will only have access.

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* 1. Location and date of Incident (Event/Venue)

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* 2. Can you describe in a few short lines what happened?

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* 3. How would you rate the professionalism of our staff throughout your interaction?

Extremely professional

Very professional

Somewhat professional

Not so professional

Not at all professional

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* 4. Where you treated with dignity and respect throughout your treatment?

Yes

No

Other (please specify)

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* 5. If you were in pain, was it managed?

Yes

No

Other (please specify)

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* 6. Would you describe your transfer to hospital reasonably comfortable and safe?

Yes

No

Other (please specify)

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* 7. Were you informed of your treatment and interventions (if any) at all times?

Yes

No

Other (please specify)

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* 8. Can you rate your satisfaction of the care and treatment you received?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

Other (please specify)

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* 9. If you have any other feedback about your experience, please write in the space below.

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* 10. Would you like to be contacted by the Codeblue Aftercare Team

Yes

No

If Yes (please specify)
Name:
Address:
City/Town:
Country:
Email Address:
Phone Number: