Non Emergency Patient Survey

 

Section 1 - About The Service You Received
1) Who usually books your non-emergency ambulance transport?	GP Hospital Myself Carer/Relative Other
Other (please state)
2) If you booked the transport yourself did you find it easy to do?	Yes No
3) Were you told what time you would be picked up?	Yes No
4) The following questions are about your journey:
a) Were you on the vehicle for longer than one hour?	Yes No
b) Was the vehicle clean and tidy?	Yes No
c) Was the vehicle driven carefully?	Yes No
d) Did the type of vehicle meet your physical needs?	Yes No
e) Were you secured in the vehicle, by seatbelt or other means?	Yes No
f) Did the ambulance crew escort you to the reception desk of your destination and ensure that staff were made aware of your arrival?	Yes No
g) Did you arrive for your appointment time (please tick one):	More than 30mins early 15 to 30mins early On time 15 to 30 mins late More than 30mins late
5) If your appointment was longer or shorter than anticipated, was your planned return ambulance transport journey rearranged?	Yes No
6) Were you given an estimate of the waiting time for your return journey?	Yes No
7) How would you describe the way ambulance staff treated you? (tick all as appropriate):	Polite and Friendly Caring and Respectful Reassuring Rude Uncaring Unhelpful
8) Do you have any further comments?
If you would like to tell us in person about your experience, please contact our Patient Experience Team on 01384 246370.
9) Where do you live? Please enter the first part of your postcode (e.g. CV34 or DY5)
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:
1) Are you:	Do not wish to disclose Male Female
2) Are you:	Do not wish to disclose my age Under 18 18 - 25 26 - 35 36 - 50 51 - 70 Over70
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):
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:
5) Which term best describes your sexuality:	Do not wish to disclose Bisexual Gay Heterosexual Lesbian
6) Please indicate your religion or belief:	Do not wish to disclose Atheism Buddhism Christianity Hinduism Islam Jainism Sikhism Other
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.
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	Learning Disability/Difficulty Long-Standing Illness Mental Health Problem Physical Impairment Sensory Impairment Other
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:
Submit

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