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Unit 12, 1st floor, 1 Melrose Boulevard
Melrose Arch, Johannesburg 2191
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Reception & casualty Feedback Survey
Hospital
*
Select Hospital
Abaqulusi Private Hospital
Medical Hospital of Lebowakgomo (MEDLEB)
RH Phodiclinic
RH Piet Retief Private Hospital
RH Rand Hospital
Age
Gender
*
Male
Female
Other
Name & Surname
Admission/Reception
Waiting time
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0
1
2
3
4
Warmth of staff
*
0
1
2
3
4
Explained casualty fees
*
0
1
2
3
4
Directions
*
0
1
2
3
4
Efficiency
*
0
1
2
3
4
Casualty facilities and non nursing
Cleanliness of unit and bathrooms
*
0
1
2
3
4
Politeness of non-nursing staff
*
0
1
2
3
4
Nursing Care
Competence and professionalism
*
0
1
2
3
4
Explanation of treatment and procedures
*
0
1
2
3
4
Respect for privacy and dignity
*
0
1
2
3
4
Treated with courtesy and resprect
*
0
1
2
3
4
Listened carefully to you
*
0
1
2
3
4
Explained things in a way you could understand
*
0
1
2
3
4
Doctor Care
Treated you with courtesy and respect
*
0
1
2
3
4
Listened carefully to you
*
0
1
2
3
4
Explained things in a way you could understand
*
0
1
2
3
4
Specialised units
Did you do an X-Ray?
*
Yes
No
X rays
*
0
1
2
3
4
Did you do blood samples?
*
Yes
No
Blood Sampling
*
0
1
2
3
4
Did you go to theatre?
*
Yes
No
Theatre
*
0
1
2
3
4
Going home
Did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?
*
Yes
No
Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
*
Yes
No
Family and access to casualty
Support to family
*
0
1
2
3
4
Access
*
0
1
2
3
4
Hospital
Please rate our hospital
*
0
1
2
3
4
5
6
7
8
9
10
Would you recommend this hospital to your friends and family?
*
0
1
2
3
4
Staff
During your hospital stay, was there one staff member who did a particularly good job or put in extra effort to care for you?
*
Yes
No
Please provide the staff member's name
*
How was this staff member was most helpful
*
Friendly, caring, helpful
Dedicated, attentive, responsive, available
Compassionate, provided comfort, reassurance, listening
Knowledgeable, provided extra information, kept patient company
Specially skilled in their job
Proactive arrangements made for patient
General information
How did you hear about us?
How did you hear about us?
Ambulance
Emergency
Flyer
Word of mouth
GP
Referal
Hospital Staff
Internet
Live in area
Media
Work here
Other staff
Passing
Previous Admission
School Tour
Signage
Specialist
Transfer
Visitor
Residential Suburb
Referring doctor
Comments
What could we have done to make your stay with us better?
What did you like the most about your stay with us?
Additional comments
Contact number
Email Address
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