Assessment of the Emergency Department from a Sensory Perspective

Assessment tool for autistic patients

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* 1. Does the information you will be providing relate to a visit to the Emergency Department at Leeds Teaching Hospitals in the 12 months?

Yes

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* 2. Please confirm the date and time you are completing this form?

Date

Time

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* 3. Are you Autistic?

Yes

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* 4. Are you completing this about your own experience?

Yes

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* 5. Are you completing this on behalf of someone Autistic?

Yes

For each area please give a rating of
1 - Unacceptable
2 - Poor
3 - Fair
4 - Good
5 - Excellent

If you are able to give additional comments these will be helpful for service improvement.

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* 6. Car Park - Lighting

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* 7. Car Park - Noise

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* 8. Car Park - Smell

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* 9. Car Park - Seating

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* 10. Car Park - Signage

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* 11. Car Park - Number of people in the area

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* 12. Car Park - Temperature

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* 13. Comments - In relation to the Car Park both positive and negative comments are appreciated?

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* 14. Entrance - Lighting

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* 15. Entrance - Noise

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* 16. Entrance - Smell

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* 17. Entrance - Seating

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* 18. Entrance - Signage

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* 19. Entrance - Number of people in the area

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* 20. Entrance - Temperature

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* 21. Comments - In relation to the Entrance both positive and negative comments are appreciated?

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* 22. Reception Area - Lighting

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* 23. Reception Area - Noise

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* 24. Reception Area - Smell

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* 25. Reception Area - Seating

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* 26. Reception Area - Signage

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* 27. Reception Area - Number of people in the area

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* 28. Reception Area - Temperature

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* 29. Comments - In relation to the Reception Area both positive and negative comments are appreciated?

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* 30. Waiting Area - Lighting

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* 31. Waiting Area - Noise

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* 32. Waiting Area - Smell

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* 33. Waiting Area - Seating

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* 34. Waiting Area - Signage

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* 35. Waiting Area - Number of people in the area

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* 36. Waiting Area - Temperature

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* 37. Comments - In relation to the Waiting Area both positive and negative comments are appreciated?

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* 38. Treatment Room - Lighting

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* 39. Treatment Room - Noise

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* 40. Treatment Room - Smell

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* 41. Treatment Room - Seating

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* 42. Treatment Room - Signage

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* 43. Treatment Room - Number of people in the area

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* 44. Treatment Room - Temperature

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* 45. Comments - In relation to the Treatment Room both positive and negative comments are appreciated?

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* 46. If you found the environment unsuitable how helpful were the staff at offering adaptations?