LINES ARE OPEN 24/7 – CALL US NOW ON 0345 1220 743PATIENT FEEDBACK Order Number We would be greatful if you would answer the following questions regarding your experience with our patient transport services. Your feedback is important to us for our continuous service improvement. How likely are you to recommend our patient transport service to friends and family if they needed similar care or treatment? * Extremely likely Likely Neither likely or unlikely Unlikely Extremely unlikely Don't know What is the main reason for the answer you have chosen? * Which county were you collected from? * Which hospital/clinic did you attend? * Who usually books your non-emergency transport? * GP Hospital Yourself Carer/relative Other If you booked the transport yourself, did you find it easy to do? * Yes No Not applicable Did you arrive for your appointment on time? * More than 30 minutes early 15-30 minutes early On time 15-30 minutes late More than 30 minutes late Did your transport home leave on time? * More than 30 minutes early 15-30 minutes early On time 15-30 minutes late More than 30 minutes late Was the vehicle... Clean and tidy? * Yes No Suitable for your needs? * Yes No Comfortable? * Yes No Driven carefully? * Yes No Did the transport crew escort you to the reception desk of your destination and ensure that staff were made aware of your arrival? * Yes No Not required Overall how satisfied were you with the quality of service you received? * Very satisfactory Above satisfactory Satisfactory Unsatisfactory Very unsatisfactory Any other comments? There is now a short section of questions about you. This is entirely voluntary but by completing it you will help us understand more about our patients and also meet our duties under the Equality Act. How old are you? 14-16 17-21 22-29 30-39 40-49 50-59 60-74 75+ What is your gender? Male Female Prefer not to say Do you consider yourself to have a disability? Yes No Prefer not to say Do you consider yourself to have a mental health, dementia or learning disability diagnosis? Yes No Prefer not to say Your Ethnicity White British White Irish Other White White & Black Caribbean White & Black African Mixed - any other background White & Asian Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Carribean Asian or Asian British - African Asian or Asian British - Any other black background Other Ethnic Groups - Chinese Other Ethnic Groups - Any other Other Mixed Background Prefer not to say Your Religion or Belief? Buddhist Christian (including Church of England, Catholic, Protestant and all other Christian denominations) Hindu Jewish Muslim No religion Sikh Prefer not to say Any other religion or belief Please tell us whether you consider yourself to be any of the following (please tick all that apply or leave blank if none apply) SCAS staff member SCAS volunteer Public Member Governor Staff member from other NHS organisation Councillor Local Healthwatch Member Patient (rare use of patient transport services) Patient (regular use of patient transport services) GP MP Mayor
