ICU Family Survey

 
1. In which ICU did your family receive care?
2. What month did your family member receive care in the ICU?
3. How often were you satisfied with the availability of the doctor to speak with you on a regular basis?
4. How often were you satisfied with the nurse's ability to speak with you every day about your family member's care?
5. How often were you provided with clear explanations of the tests, procedures, and treatments?
6. How often were you satisfied that you were able to share in decisions regarding your family member's care?
7. How often were you satisfied with the support and encouragement given to you during your family member's stay in the ICU?
8. How often were you satisfied with the flexibility of the visiting times?
9. How often did you find the waiting area peaceful and safe?
10. How often were you satisfied with the cleanliness and appearance of the waiting area?
11. Using any number from 0-10, where 0 is the worst experience possible and 10 is the best experience possible, what number would you use to rate your overall experience as a family member of a patient in this ICU?
12. Comments:
13. Would you like to be contacted regarding any of your responses, positive or negative?
14. Respondent Name (optional)
Patient Name (optional)
Physician Name (optional)
e-mail (optional)
phone # (optional)
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