Emergency & Urgent Patient Survey

Section 1 – About the service you received

1) Can you remember the date of the incident?	No Yes
If yes please state
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2) Are you	Patient Caller
Other (please state)
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3) Did you contact any of the following before calling 999/112?	GP Surgery Hospital NHS Direct Out of Hours Doctor’s Service Pharmacy Walk-in Centre Other Not Applicable
If yes what advice was given?
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4) Did the ambulance call taker listen to all of your details carefully?	Not Applicable Yes No Can’t remember
If an ambulance was not required then please go to Question 11
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5) Did the ambulance call taker give advice in a reassuring manner?	Not Applicable Yes No Can’t remember
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6) Did the ambulance crew / responder who came to you, ask about your medical history?	Not Applicable Yes No Can’t remember
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7) Did the ambulance crew / responder explain your care and treatment to you in a way that was easy to understand?	Not applicable Yes definitely Yes to some extent Yes but not in a way I was able to understand No explanation was given Can’t remember
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8) How involved did you feel you were in the decisions made regarding your care?	Not Applicable Very involved Fairly involved Not involved Can’t remember
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9) Were you………	Can't remember Treated and left where you were? Taken to Hospital? Taken to another healthcare facility such as a primary care centre or walk in centre? Referred to GP or Other Healthcare Provider?
10) How would you describe the following?
a) The cleanliness of the interior of the ambulance	Can’t remember Good Acceptable Fairly Acceptable Unacceptable
b) The appearance of the ambulance service staff	Can’t remember Good Acceptable Fairly Acceptable Unacceptable
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11 a) Were you dealt with politely and sensitively by all West Midlands Ambulance Service staff?	Can’t remember Yes No
11 b) Do you feel that the ambulance service treated you with dignity and respect?	Can’t remember Yes No
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12 a) Overall would you say that the service you received from West Midlands Ambulance Service was:	What you expected Better then you expected Worse then you expected
b) If you have any further comments then please state below:
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Section 2 – About you
At West Midlands Ambulance Service we strive to ensure that we provide the best possible service to all members of the community that we serve. It would therefore help us if you could answer the following questions:
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1) Are you	Do not wish to disclose Male Female
2) Are you	I do not wish to disclose my age Under 18 18 – 25 26 – 35 36 - 50 51 – 70 Over 70
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3) In which area did the incident take place:	Do not wish to disclose Birmingham Black Country Coventry and Warwickshire Herefordshire Shropshire Staffordshire Worcestershire
Other (please state)
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4) Are you:	Do not wish to disclose Asian or Asian British: Bangladeshi Asian or Asian British: Indian Asian or Asian British: Other Asian Asian or Asian British: Pakistani Black or Black British: Black African Black or Black British: Black Caribbean Black or Black British: Other Black Chinese or Other Ethnic Group: Chinese Chinese or Other Ethnic Group: Other Ethnic Group Mixed: Other Mixed Mixed: White and Asian Mixed: White and Black African Mixed: White and Black Caribbean White: British White: Irish White: Other White
If other please state
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5) Which term best describes your sexuality	Do not wish to disclose Bisexual Gay Heterosexual Lesbian
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6) Please indicate your religion or belief	Do not wish to disclose Atheism Buddhism Christianity Hinduism Islam Jainism Sikhism Other
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7) Do you consider yourself to have a disability/impairment?	Do not wish to disclose Yes No
If yes then please go to Question 8 and indicate all that apply to you.
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8) Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more then one. If none of the categories apply, please mark Other	Other Learning disability/difficulty Long-standing illness Mental Health Problem Physical Impairment Sensory Impairment
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Please be assured that all information will remain anonymous. If you have any queries or wish to discuss in further detail then please contact the Patient Experience Department on 01384 246370 or email patient.survey@wmas.nhs.uk. If you would like us to contact you, please leave your name and number below.
Name
Contact Number
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