Carer questionnaire Survey

Jackie Petley has recently started at University Hospitals Southampton as the Carers’ Experience Lead. Jackie would like to find out the experiences of carers of people who have either been admitted to the hospital or attended as an outpatient.

Your experiences and views are vital in developing the support and resources you receive while at the hospital.

Would you please answer the following questions in as much detail as you feel able?

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* 1. How could we improve your experience as a carer of someone admitted to hospital?

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* 2. How could we improve your experience as a carer of someone attending an outpatient appointment?

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* 3. Please tell me what went well and how this improved your experience

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* 4. Please tell me what didn’t go so well and how this affected you?

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* 5. If you were admitted to hospital, do you have an Emergency Plan in place to support the person you care for?

Yes

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* 6. If No to question 5, would like support in preparing an Emergency Plan?

Yes

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* 7. If you would like support in preparing an emergency plan, please leave your name and either telephone or email address below:

Name

Email Address

Phone Number

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* 8. What age category are you in?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 9. Are you:

Male

Female

Gender neutral

Other

Prefer not to say

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* 10. Do you consider yourself to have a physical impairment?

Yes

Prefer not to say

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* 11. What is your ethnicity?

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British - Bangladeshi

Any other Asian background

Black or Black British - Caribbean

Black or Black British - African

Any other Black background

Chinese

Other ethnic group

Mixed - White and Black Caribbean

Mixed - White and Black African

Mixed - White and Asian

Any other Mixed background

White British/Welsh/Scottish

White Irish

Any other White background

Prefer not to say

Thank you for taking the time to complete this survey.

Protecting your information

·         We will ensure that your information is kept secure at all times

·         Use your information to provide the best care possible

·         Not share your information with anyone else unless permitted to do so by the law.

·         Provide you with copies of your health records, upon request

We have secure systems to store your information, controls to restrict the people who can access it and monitoring of our systems to ensure that any breaches can be identified. Those accessing your information may include doctors, nurses, other medical professionals and administrative staff.