Customer Feedback Form Question Title * 1. Date of your journey? Date / Time Question Title * 2. Which Hospital were you discharged / transferred from or the hospital you were taken to? Question Title * 3. Based on your experience of our service, how likely are you to recommend us to family and friends if they needed similar transport? Extremely Likely Likely Neither Likely or unlikely Unlikely Extremely unlikely Please tell us why you gave this response? Question Title * 4. Please select the following based on your journey experience. The crew introduced themselves. The crew explained what would be happening on the journey. I was allowed to ask questions. I was treated as an individual with dignity and respect by the ambulance crew. The ambulance crew understood my needs. I arrived at my destination in a reasonable length of time. The vehicle used to transport me was suitable for purpose, easy to access, clean and comfortable. Thinking of the service I received from the ambulance crew, I believe they my needs and expectation of the service were met. Question Title * 5. Please select if you are: The patient. The Carer Other Male Female Question Title * 6. What is your ethnic group? White Mixed / Multiple ethnicity Asian / Asian British Black / African / Caribbean / Black British Other ethnic group Question Title * 7. Are your day to day activities limited because of a health problem or disability which has lasted or is expected to last at least 12 months (include any issues or problems related to old age) Yes - limited a lot Yes - limited a little No Prefer not to say Question Title * 8. We would like to share your comments anonymously on our website. Please confirm that you are happy for us to share the results and feedback of this survey. Yes No Done