Service User Satisfaction Feedback Survey

The NHS Wheelchair Service is committed to improving the service that we provide. To do this, we need your feedback. 

This is a secure website. AJM Healthcare will not disclose any of your information to any third party. 

AJM will treat all the information provided in the strictest of confidence. 

*These questions require a response, please type N/A if you do not wish to provide this information

We thank you for your time to complete the survey.

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* 1. Which CCG area do you live in? 

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* 2. Are you or the Service User (please select one option)

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* 3. Are you (please select one option)

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* 4. When was the date of your appointment or visit? This is the date you saw the therapist or technician either at home or a clinic. 

Date

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* 5. What is the staff ID code of the AJM therapist, engineer or technician who saw you? (If you don't know their code please ask them or provide their name) 

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* 6. What was the reason for the visit? (If unknown, ask your AJM therapist, engineer or technician)

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* 7. NHS Friends and Family Test
Would you tell your friends and family to use this service, if they needed a wheelchair?

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* 8. General Questions (Tick 'Not Applicable' if not relevant to this visit)

  Very Satisfied  Satisfied  Neither Satisfied nor Dissatisfied  Dissatisfied Very Dissatisfied N/A
Did the wheelchair service staff treat you with dignity and respect?
Were you seen at a convenient time?
Did they listen to you?
Did you understand what they told you?

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* 10. Clinical Assessment Questions (Tick 'Not Applicable' if not relevant to this visit)

  Very Satisfied Satisfied  Neither Satisfied nor Dissatisfied Dissatisfied Very Dissatisfied N/A
Were you involved in making decisions about your care?
Did you get the care or service that you needed?
Were the needs of your carer or personal assistant met?
Were you happy with the time it took from referral to being seen?
Were you happy with the referral booking process? 
How satisfied are you with the information that we provided to you about Personal Wheelchair Budgets?

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* 11. Provision of equipment

  Very Satisfied  Satisfied  Neither Satisfied nor Dissatisfied Dissatisfied Very Dissatisfied N/A
Were you happy with the time it took from your assessment to receiving your wheelchair or other equipment?
How satisfied were you with the support and training given to you about the use of your wheelchair when it was provided?
Has the provision of equipment improved your posture  
Has your level of independence increased following provision of equipment  

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* 12. Wheelchair Repair and Maintenance (tick 'Not Applicable' if not relevant to this visit)

  Very Satisfied  Satisfied  Neither Satisfied nor Dissatisfied Dissatisfied Very Dissatisfied N/A
How satisfied were you with the quality of the work completed?

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* 13. Please add any detail or further comments on the above questions:

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* 14. What did the Wheelchair Service do well?

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* 15. How could we improve the service?

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* 16. Please be assured that the AJM management team and the NHS, want to hear about any part of the service that has fallen short of your expectations. By providing us with your name and postcode we will be able to complete a thorough review of the services provided and make necessary changes to ensure that lessons are learnt.

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* 17. What is your name?  

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* 18. What is your date of birth? use today's date if you wish to remain anonymous

Date
 
50% of survey complete.

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