Patient experience and complaints survey

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* 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)

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* 2. How did you make contact with the CCG Patient Experience and Complaints team?

Telephone

Letter

Other (please specify)

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* 3. Were you given a single point of contact for the Patient Experience and Complaints team?

Yes

Unsure

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* 4. Were you advised of the NHS Complaints Advocacy Service and given the contact details?

Yes

Unsure

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* 5. Was the complaints process explained to you?

Yes

Unsure

Other (please specify)

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* 6. Did you feel the complaints staff listened to and understood your concerns?

Yes

If no, please explain

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* 7. Did you receive appropriate advice/information when you asked?

Yes

If no, please explain

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* 8. Overall how satisfied, were you with the service you received:

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

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* 9. Do you have any feedback or suggestions regarding our service?

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* 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

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* 11. Age group:

16-17

18-24

25-34

35-44

45-54

55-64

65-74

75+

Prefer not to say

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* 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

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* 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

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* 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

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* 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

Prefer not to say

Other (please specify)