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Ambulance Service Questionnaire (PDF)

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					                                                                                CALLING THE AMBULANCE
                                                                     Please remember, this questionnaire is about your
                                                                     most recent experience of the ambulance
                                                                     emergency or urgent services.
     Ambulance Service                                               1. Where were you when the ambulance was
                                                                           called?
       Questionnaire
                                                                       1        At my home
    Emergency and Urgent 999 Calls
                                                                       2        In a public place

                                                                       3        Somewhere else
What is the survey about?
                                                                       4        Don’t know/ Can’t remember
This survey is about your most recent experience
of the ambulance emergency or urgent services.

                                                                     2. Who called the ambulance?
Who should complete the questionnaire?
                                                                       1        I did                             Go to 3
The questions should be answered by the person
named on the front of the envelope. If that person                     2        A friend or relative              Go to 3
needs help to complete the questionnaire, the
answers should be given from his/her point of view –                   3        A doctor/NHS Direct               Go to 7
not the point of view of the person who is helping.
                                                                       4        The police                        Go to 7

                                                                       5        A stranger                        Go to 7
Completing the questionnaire.
                                                                       6        Other                             Go to 7
For each question please tick clearly inside one box
using a black or blue pen.                                             7        Don’t know/ Can’t remember        Go to 7

Sometimes you will find the box you have ticked has
an instruction to go to another question. By following
the instructions carefully you will miss out questions               3. Did the ambulance call taker listen carefully?
that do not apply to you.
                                                                     100    1      Yes, definitely
Don’t worry if you make a mistake; simply cross out
the mistake and put a tick in the correct box.                        50    2      Yes, to some extent
Please do not write your name or address anywhere                      0    3      No
on the questionnaire.
                                                                       -    4      Don’t know/ Can’t remember

    Your participation in this survey is
                voluntary.
                                                                     4. Did the ambulance call taker easily understand
If you choose not to take part in this survey it will not                  your location?
affect the care you receive from the NHS in any
way. If you do not wish to take part, or you do not                  100    1      Yes
want to answer some of the questions, you do not
                                                                       0    2      No
have to give us a reason.
                                                                       -    3      Don’t know/ Can’t remember
Your answers will be treated in confidence.




                  National Survey Programme. Ambulance Emergency and Urgent Questionnaire v5. 21/11/03   Page 1
5. Did the ambulance call taker give advice on the                    10. Were the ambulance crew reassuring?
      phone about what to do before the ambulance
      arrived?                                                        100    1    Yes, definitely

100    1    Yes                                                       50     2    Yes, to some extent

  0    2    No                                                          0    3    No

  -    3    Don’t know/ Can’t remember                                  -    4    Don’t know/ Can’t remember

  -    4    No advice was wanted/ needed
                                                                      11. Did the ambulance crew explain your care and
                                                                            treatment in a way you could understand?
6. Was the ambulance call taker reassuring?
                                                                      100    1    Yes, definitely
100    1    Yes, definitely
                                                                      50     2    Yes, to some extent
50     2    Yes, to some extent
                                                                        0    3    No
  0    3    No
                                                                        -    4    Don’t know/ Can’t remember
  -    4    Don’t know/ Can’t remember

                                                                      12. Did the ambulance crew talk in front of you as if
           THE AMBULANCE CREW                                               you weren’t there?

7. Did the ambulance crew listen carefully?                             0    1     Yes, definitely

100    1    Yes, definitely                                           50     2     Yes, to some extent

50     2    Yes, to some extent                                       100    3     No

  0    3    No                                                          -    4     Don’t know/ Can’t remember

  -    4    Don’t know/ Can’t remember
                                                                      13. Did the ambulance crew do everything they
                                                                            could to help control your pain?

                                                                      100    1     Yes, definitely
8. Did the ambulance crew ask about your previous
      medical history?                                                50     2     Yes, to some extent

100    1    Yes                                                         0    3     No

  0    2    No                                                          -    4    I did not have any pain

  -    3    Don’t know/ Can’t remember
                                                                      14. If friends or relatives were with you, were they
                                                                            given enough information about your care and
                                                                            treatment?
9. Did you have trust and confidence in the
      ambulance crew’s professional skills?                           100    1    Yes

                                                                        0    2    No
100    1    Yes, definitely
                                                                        -    3    No friends or relatives were with me
50     2    Yes, to some extent
                                                                        -    4    Don’t know/ Can’t remember
  0    3    No

  -    4    Don’t know/ Can’t remember



                   National Survey Programme. Ambulance Emergency and Urgent Questionnaire v5. 21/11/03   Page 2
            TRANSFER TO HOSPITAL                                                    IF YOU WERE NOT TAKEN TO
                                                                                            HOSPITAL
Still thinking about the last time you used the
emergency and urgent ambulance services…                                  Please answer questions 20-22 if the last time you
                                                                          used the emergency and urgent ambulance services
15. Were you taken to a hospital in the ambulance?
                                                                          you were NOT taken to hospital.
 1         Yes          Go to 16                                          20. Did the ambulance crew advise you to go to
                                                                                hospital?
 2         No           Go to 20
                                                                            1           Yes, but I refused

16. Was the way you got into the ambulance                                  2           No
      suitable? (e.g. by walking, on a stretcher etc.)
                                                                          21. Did you agree with the decision not to go to
100    1        Yes
                                                                                hospital?
  0    2        No
                                                                          100    1           Yes
  -    3        Don’t know/ Can’t remember
                                                                            0   2         No

17. How clean was the ambulance?
                                                                            -   3         Not sure


100 1           Very clean                                                22. Did the ambulance crew give you advice about
                                                                                what to do if you felt unwell again?
67    2         Fairly clean
                                                                          100    1           Yes
33    3         Not very clean
                                                                            0    2           No
  0   4         Not at all clean
                                                                            -    3           Don’t know/ Can’t remember
  -   5      Don’t know/ Can’t remember
                                                                            -    4           No advice was wanted/ needed

18. Did the ambulance driver take care to make the                                                    OVERALL
      journey as comfortable as possible?
                                                                          23. Overall, how would you rate the care you
100    1        Yes, definitely                                                 received from the ambulance service?

50     2        Yes, to some extent                                       100    1           Excellent

  0    3        No                                                        80     2           Very good

  -    4        Don’t know/ Can’t remember                                60     3           Good

                                                                          40     4           Fair
19. As far as you know, did the ambulance crew give
                                                                          20     5           Poor
      hospital staff all the necessary information about
      you?                                                                  0    6           Very poor

100    1        Yes
                                                                          24. Overall, did the ambulance crew treat you with
  0    2        No                                                              respect and dignity?
  -    3        Don’t know/ Can’t remember                                100       1        Yes, definitely

                                                                          50        2        Yes, to some extent
           Now please go to Question 23
                                                                            0       3        No

                                                                            -       4        Don’t know/ Can’t remember
                       National Survey Programme. Ambulance Emergency and Urgent Questionnaire v5. 21/11/03    Page 3
                  ABOUT YOU                                         26. Are you male or female?

25. To which of these ethnic groups would you say                      1       Male
    you belong? (Tick ONE only)
                                                                       2       Female
    a. WHITE
    1          British
                                                                    27. What was your year of birth?
    2          Irish
                                                                       (Please write in)           e.g.     1    9   3   4
    3          Any other White background
               (Please write in box)                                                  1        9

                                                                                   OTHER COMMENTS
    b. MIXED
                                                                    If there is anything else you would like to tell us
    4          White and Black Caribbean
                                                                    about your experiences of the ambulance
    5          White and Black African                              emergency and urgent services, please do so here.

    6          White and Asian

    7          Any other Mixed background                                  Was there anything particularly good about
                                                                           your care?
               (Please write in box)




    c. ASIAN OR ASIAN BRITISH
    8          Indian

    9          Pakistani
                                                                           Was there anything that could have been
    10         Bangladeshi                                                 improved?

    11         Any other Asian background
               (Please write in box)




    d. BLACK OR BLACK BRITISH
                                                                           Anything else?
    12         Caribbean

    13         African

    14         Any other Black background
               (Please write in box)




    e. CHINESE OR OTHER ETHNIC GROUP                                   THANK YOU VERY MUCH FOR YOUR HELP
                                                                             Please check that you answered all the
    15         Chinese
                                                                                  questions that apply to you.
    16         Any other ethnic group                                      Please post this questionnaire back in the
               (Please write in box)                                            FREEPOST envelope provided.
                                                                                          No stamp is needed.


                 National Survey Programme. Ambulance Emergency and Urgent Questionnaire v5. 21/11/03   Page 4

				
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