Name of Patient

(Optional)

First Name

Last Name

Name of Respondent

First Name

Last Name

Role

Patient

Family Member

Caregiver

Other

Date of Service

MM

DD

YYYY

Rate our service in Area of Care

(Please ✓ the most appropriate response)

1. Courtesy and professionalism of staff

Excellent

Good

Fair

Poor

Not Applicable

2. Timeliness of response to your needs

Excellent

Good

Fair

Poor

Not Applicable

3. Communication and explanation of care

Excellent

Good

Fair

Poor

Not Applicable

4. Comfort and pain relief provided

Excellent

Good

Fair

Poor

Not Applicable

5. Emotional and psychosocial support

Excellent

Good

Fair

Poor

Not Applicable

6. Coordination with hospital or other providers

Excellent

Good

Fair

Poor

Not Applicable

7. Respect for patient’s and family’s wishes

Excellent

Good

Fair

Poor

Not Applicable

8. Overall quality of home palliative care service

Excellent

Good

Fair

Poor

Not Applicable

Open Feedback

Consent (Optional)

I give consent for my feedback to be used (anonymously) for quality improvement and/or promotional purposes.