FFT

FFT FEEDBACK FORM - DR SHANTIR'S PRACTICE

We would like to you to think about your recent experience of the service.

Everyone working for the NHS has a legal duty to keep information about you confidential.

Please complete all questions, all the information you supply us with will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you and sets out the rules to make sure that this information is handled properly.

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* 1. How likely are you to recommend our service to friends and family if they needed simmilar care or treatment?

Extremely likely

Likey

Neither/Nor Unlikely

Unlikely

Extremely Unlikely

Don't Know

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* 2. What is the main reason for your answer to question 1?

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* 3. Are you?

Male

Female

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* 4. How old are you?

0-15 years of age

16-24 years of age

25-34 years of age

35-44 years of age

45-54 years of age

55-64 years of age

65-74 years of age

75-84 years of age

84 years of age over

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* 5. Do you consider yourself to have a disability?

Yes

Details:

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* 6. Which of the following describes your ethnic background?

White

Irish

Other White background

Indian

Pakistani

Bangladeshi

Chinese

Other Asian background

White and Black Carribbean

White and Black African

White and Asian

Other mixed background

Carribbean

African

Other Black background

Anything else

I would rather not say

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* 7. Who was the main person who answered the questions?

Me, the patient

Me, the parent or carer

Both the carer/patient

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* 8. Do you wish the anonymous comments to be shared?

Yes