Patient experience and complaints survey Question Title * 1. Where did you find out how to contact the Patient Experience and Complaints team? NHS Birmingham and Solihull CCG's website NHS England A provider organisation e.g. hospital, mental health service Other (please specify) OK Question Title * 2. How did you make contact with the CCG Patient Experience and Complaints team? Telephone Letter Email Other (please specify) OK Question Title * 3. Were you given a single point of contact for the Patient Experience and Complaints team? Yes No Unsure OK Question Title * 4. Were you advised of the NHS Complaints Advocacy Service and given the contact details? Yes No Unsure OK Question Title * 5. Was the complaints process explained to you? Yes No Unsure Other (please specify) OK Question Title * 6. Did you feel the complaints staff listened to and understood your concerns? Yes No If no, please explain OK Question Title * 7. Did you receive appropriate advice/information when you asked? Yes No If no, please explain OK Question Title * 8. Overall how satisfied, were you with the service you received: Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied OK Question Title * 9. Do you have any feedback or suggestions regarding our service? OK Question Title * 10. Please state your sex: Male Female Intersex (Someone born with both male and female reproductive organs) Do you identify as trans*?(*Any part of a process, including thoughts or actions, to bring your physical sex appearance, and/or your gender role, more in line with your gender identity) Prefer not to say OK Question Title * 11. Age group: 16-17 18-24 25-34 35-44 45-54 55-64 65-74 75+ Prefer not to say OK Question Title * 12. How would you describe your ethnic background? Asian or Asian British: Bangladeshi Asian or Asian British: Chinese Asian or Asian British: Indian Asian or Asian British: Pakistani Asian: Other Black or Black British: African Black or Black British: Caribbean Black: Other Mixed: White and Asian Mixed: White and Black African Mixed: White and Black Caribbean Mixed: Other White: English/Welsh/Scottish/Northern Irish/British White: Irish White: Gypsy or Irish Traveller White: Other Other: Arabic Other: Other ethnic background Prefer not to say OK Question Title * 13. How would you describe your religion or beliefs? Agnostic Atheist Buddhist Christian Hindu Jewish Muslim Pagan Sikh None Any other religious belief Prefer not to say OK Question Title * 14. Please indicate which term would best describe your sexual orientation Asexual (Someone who is not attracted any sex) Bisexual (Someone who is attracted to both males and females) Gay or lesbian (Someone who is attracted to the same sex as themselves) Heterosexual (Someone who is attracted to the opposite sex) None of these Prefer not to say OK Question Title * 15. Do you have a disability? Vision or sight impairment (such as blindness or partial sight) Hearing (such as deafness or being hard of hearing) Physical mobility (such as being a wheelchair user or using walking aids) Dexterity (such as difficulty lifting or carrying) Learning difficulty (such as autism, Asperger's syndrome, dyslexia or dyspraxia) Mental health problems (such as anxiety, depression, bi-polar, schizophrenia, eating disorder) Long term health condition e.g. asthma, COPD No Prefer not to say Other (please specify) OK DONE