Hospice Satisfaction Survey Form

* Required Information

Date

Thank you for allowing us to provide services to your family. We are interested in your ideas or opinions about our program. Please take a moment to answer the following questions. Additional comments are welcome and can be recorded on the back of this form. If you need assistance in completing this form, please feel free to contact our office.

For questions 1-10, please circle the appropriate number that best describes your opinion.

1 - Strongly Agree 2 – Agree 3 – Disagree 4 – Strongly Disagree 5 – No Opinion or N/A

1. We were satisfied with the care provided by the hospice staff.

2. Medication/Supplies were delivered on time.

3. Equipment was delivered on time.

4. We were involved in decision making regarding the plan of care our family.

5. Staff treated our family, our home and belongings with respect.

6. Staff explained care, services, rights and responsibilities, and other procedures related to the care provided.

7. We were able to reach hospice staff in a timely manner whenever necessary.

8. We would recommend this hospice to friends and relatives.

9. Staff provided emotional support during our hospice experience.

10. Staff assisted with managing our loved one/family member’s pain and symptom control.

11. Suggestions for improvements/additional comments

12. What most impressed us about the hospice care/services was

How long did you receive hospice services:

Less than 1 month	1-3 months
3-6 months	6-9 months
9-12 months	greater than 12 months

Thank you for your valuable feedback. This confidential information will be used only in efforts to improve care/services.

Sincerely,

Director/Administrator *

We would not like to discuss our responses further. Please return the completed survey in the enclosed, self-addressed stamped envelope.

Name *

Date *