Friends and family test for PTS

We would like you to think about your recent contact with our Patient Transport Service.

Please provide journey date/ month:

Please provide the first part of postcode:

Overall, how was your experience of our service?

Very Good Good Neutral Bad Very Bad

Please rate from Very Good to Very Bad:

Thinking about the service we provided...

Please can you tell us why you gave this answer?*

Please tell us about anything that we could have done better?*

Please confirm whether you are happy for your comments to be made public:*

Would you like to compliment the service or staff?

If you wish to send a separate note of thanks to the initial call handler or staff involved, you may add your comments to the below box, please also include your name and contact details to ensure such correspondence is passed on to the appropriate people.

I consent to my details being held by the East of England Ambulance Service NHS Trust and I would like for my comments to be passed on to the relevant team

Full name:

Address line 1

Address line 2

Town

Region

Postcode

Country

Telephone number:

Email address:

Would you like to take part in a patient interview?

We are looking for patients who would be willing to discuss their experience with the East of England Ambulance Service NHS Trust in more depth. The information obtained from patient interviews will be used to assist us in improving the services provided by the Trust.

I consent to my details being held by the East of England Ambulance Service NHS Trust and would be interested in discussing my experience further

Full name:

Address line 1

Address line 2

Town

Region

Postcode

Country

Telephone number:

Email address:

Would you like to inform us of a concern or complaint?

All comments received are used to monitor and improve the services provided by the Trust. If you have a concern or complaint about the service you have received and would like us to contact you, please complete the below box and provide your name and telephone number:

I consent to my details being held by the East of England Ambulance Service NHS Trust and I wish to be contacted by the Patient Experience Team to register my concerns and initiate the feedback process

Full name:

Address line 1

Address line 2

Town

Region

Postcode

Country

Telephone number:

Email address:

Please be aware that you can withdraw your consent for the East of England Ambulance Service NHS Trust to use and store the information you have provided at any time. If you wish to withdraw your consent to your details being held, please contact the Patient Survey Team either via email: surveys@eastamb.nhs.uk or by telephone 01603 422757.

Equality and Diversity

The following questions are used to obtain demographic information about the patients we serve. This information can help us plan to meet the needs of the community, to ensure that everyone has equal access to the heath care provided and for the service to be delivered to a high standard for all of our patients.

What best describes your gender?

Female
Male
I do not wish to declare

Prefer to self describe:

Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? (include any issues / problems related to old age)

Yes - limited a lot
Yes - limited a little
No
I do not wish to declare

As a protection against spam, please type the letters and/ or numbers you see: *

Thank you for taking the time to assist us and providing your feedback on the service.

If you have any queries about completing the survey, please contact the Patient Survey Team via email: surveys@eastamb.nhs.uk or by telephone: 01603 422801.