North Kent Community Ophthalmology Service – Referrer satisfaction questionnaire Survey

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* 1. Are you a GP or Optometrist?

Optometrist

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* 2. Which CCG area do you work in?

Dartford, Gravesham and Swanley

Medway

Swale

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* 3. Do you refer to our service?

Yes

No (If no, please go to question 8)

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* 4. If yes, how do you refer to the Community Ophthalmology Service

A. Using the North Kent Community Ophthalmology website/online booking system

B. By telephone - contacting the Referral Management Centre

C. I do not refer patients, I provide them with the self-referral card for them to contact

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* 5. Are you also a provider of the service?

Yes

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* 6. If you have used the North Kent Ophthalmology Services, please rate your level of satisfaction with each of the following statements.

	Poor = 1	Unsatisfactory = 2	Average = 3	Good = 4	Very Good = 5
The referral process is easy and clearly defined	The referral process is easy and clearly defined Poor = 1	The referral process is easy and clearly defined Unsatisfactory = 2	The referral process is easy and clearly defined Average = 3	The referral process is easy and clearly defined Good = 4	The referral process is easy and clearly defined Very Good = 5
The North Kent Ophthalmology Service is easy to contact using the website/online booking system	The North Kent Ophthalmology Service is easy to contact using the website/online booking system Poor = 1	The North Kent Ophthalmology Service is easy to contact using the website/online booking system Unsatisfactory = 2	The North Kent Ophthalmology Service is easy to contact using the website/online booking system Average = 3	The North Kent Ophthalmology Service is easy to contact using the website/online booking system Good = 4	The North Kent Ophthalmology Service is easy to contact using the website/online booking system Very Good = 5
The North Kent Ophthalmology Service is easy to contact by telephone (contacting the Referral Management Centre)	The North Kent Ophthalmology Service is easy to contact by telephone (contacting the Referral Management Centre) Poor = 1	The North Kent Ophthalmology Service is easy to contact by telephone (contacting the Referral Management Centre) Unsatisfactory = 2	The North Kent Ophthalmology Service is easy to contact by telephone (contacting the Referral Management Centre) Average = 3	The North Kent Ophthalmology Service is easy to contact by telephone (contacting the Referral Management Centre) Good = 4	The North Kent Ophthalmology Service is easy to contact by telephone (contacting the Referral Management Centre) Very Good = 5
The North Kent Ophthalmology Service offers reduced waiting time for my patients	The North Kent Ophthalmology Service offers reduced waiting time for my patients Poor = 1	The North Kent Ophthalmology Service offers reduced waiting time for my patients Unsatisfactory = 2	The North Kent Ophthalmology Service offers reduced waiting time for my patients Average = 3	The North Kent Ophthalmology Service offers reduced waiting time for my patients Good = 4	The North Kent Ophthalmology Service offers reduced waiting time for my patients Very Good = 5
The North Kent Ophthalmology Service provides me with sufficient information on my patients following their appointment	The North Kent Ophthalmology Service provides me with sufficient information on my patients following their appointment Poor = 1	The North Kent Ophthalmology Service provides me with sufficient information on my patients following their appointment Unsatisfactory = 2	The North Kent Ophthalmology Service provides me with sufficient information on my patients following their appointment Average = 3	The North Kent Ophthalmology Service provides me with sufficient information on my patients following their appointment Good = 4	The North Kent Ophthalmology Service provides me with sufficient information on my patients following their appointment Very Good = 5
The North Kent Ophthalmology Service provides my patients with sufficient information on their condition and how to self-care	The North Kent Ophthalmology Service provides my patients with sufficient information on their condition and how to self-care Poor = 1	The North Kent Ophthalmology Service provides my patients with sufficient information on their condition and how to self-care Unsatisfactory = 2	The North Kent Ophthalmology Service provides my patients with sufficient information on their condition and how to self-care Average = 3	The North Kent Ophthalmology Service provides my patients with sufficient information on their condition and how to self-care Good = 4	The North Kent Ophthalmology Service provides my patients with sufficient information on their condition and how to self-care Very Good = 5
Overall, I am satisfied with The North Kent Ophthalmology Service	Overall, I am satisfied with The North Kent Ophthalmology Service Poor = 1	Overall, I am satisfied with The North Kent Ophthalmology Service Unsatisfactory = 2	Overall, I am satisfied with The North Kent Ophthalmology Service Average = 3	Overall, I am satisfied with The North Kent Ophthalmology Service Good = 4	Overall, I am satisfied with The North Kent Ophthalmology Service Very Good = 5

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* 7. Do you have any other comments or suggestions for improvements we can make to the service?

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* 8. What are your reasons for not referring to The North Kent Ophthalmology Service?

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* 9. Should you wish to be contacted directly regarding you feedback, please leave your name, number and email address here:

Name

Number

Email address