Patient Aftercare Survey
This survey is Private & Confidential, Senior Management of Codeblue will only have access.
1.
Location and date of Incident (Event/Venue)
2.
Can you describe in a few short lines what happened?
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
4.
Where you treated with dignity and respect throughout your treatment?
Yes
No
Other (please specify)
5.
If you were in pain, was it managed?
Yes
No
Other (please specify)
6.
Would you describe your transfer to hospital reasonably comfortable and safe?
Yes
No
Other (please specify)
7.
Were you informed of your treatment and interventions (if any) at all times?
Yes
No
Other (please specify)
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)
9.
If you have any other feedback about your experience, please write in the space below.
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:
Current Progress,
0 of 10 answered