Recently, you contacted the Patient Advice and Liaison Service (PALS) at NHS Cambridgeshire.  It is our aim to provide a high quality service and to monitor this we are asking for feedback.  We therefore hope you will take a few minutes to complete this short anonymous survey.

1.	How did you find out about PALS?
	Poster		Internet search engine		Dentist		Other
	Leaflet		Relatives/friends		Hospital
	NHS Cambridgeshire's website		GP/Practice Staff		NHS Direct

	If 'other' please specify

2.	Did you contact PALS as a ........?
	Patient		Friend/Relative/Carer		Member of Staff		Other

	If 'other' please specify

3.

Did you feel that your concerns were listened to?

Yes

No

4.

Did you feel that your concerns were taken seriously?

Yes

No

5.

Did PALS staff treat you with courtesy and respect?

Yes

No

6.	Did PALS staff ask for your consent to share information with a third party (such as your dentist or doctor?)
	Yes		No		Don't know		Not relevant

7.	Did PALS staff discuss confidentiality and data protection with you?
	Yes		No		Don't know		Not relevant

8.

Do you feel that PALS responded within a reasonable time?

Yes

No

9.

Did PALS staff provide you with a clear response to your query?

Yes

No

10.

Were PALS staff able to resolve your query or concern?

Yes

Partly

No

11.	If no, can you please explain?

12.

Did you understand what to do next if you were unhappy with your response?

Yes

No

13.	Overall, how satisfied were you with the way PALS staff dealt with your concern or query?
	Very satisfied		Satisfied		Dissatisfied		Very dissatisfied

14.	On a scale of 1-10, how likely are you to recommend PALS to a friend or relative?  (please tick a number with 1 being 'Not at all likely' to 10 being 'Extremely likely')
	1		2		3		4		5		6		7		8		9		10

15.	Please make any suggestions for improving our service in the box below:

16.

If you do not wish your comments to be included in public reports, please tick here

No Comments

17.	Month form completed:
	January		April		July		October
	February		May		August		November
	March		June		September		December

About You - please help us by providing some information about yourself (this is not compulsory)

18.

Are you male or female?

Male

Female

19.	What is your age?
	Under 18		19-24		25-44		45-60		61-70		Over 71

20.

Do you consider yourself to have a disability?

Yes

No

21.	What is your ethnic origin?
	White British		Mixed (White and Black Caribbean)		Black or Black British - Caribbean		Asian or Asian British - Bangladeshi
	White Irish		Mixed (White and Asian)		Black Other		Asian Other
	White Other		Mixed (Other)		Asian or Asian British - Indian		Chinese
	Mixed (White and Black African)		Black or Black British - African		Asian or Asian British - Pakistani		Any other ethnic group

	If 'other' please write here