FFT - Easy read format

Friends and Family Test

We would like you to think about your recent visit...

Please choose the service you visited:

Overall, how was your experience of our service?

Very good Good Neither good nor poor Poor Very poor Don't know

Please can you tell us why you gave your answer or what we could have done better?

4000 characters remaining

Can we share your comment publicly (for example, on our website or printed material such as posters)?

Yes No

Are you able to answer some additional questions about your background to help us better understand your experience of care?

Yes No

Are you:

The Patient Their Carer Their Parent/Guardian Their partner

How old are you?

0-5 years 6-10 years 11-18 years 18-25 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75-84 years +85 years Prefer not to say

How do you describe your gender?

Male Female Non-binary Prefer not to say Other (please specify)

Is your gender identity the same as the sex you were assigned at birth?

Yes No Prefer not to say

How do you describe your ethnic background?

	White British	White Irish	Gypsy or Irish Traveller	Roma	Any other White background
White background
Notes:

White background

White British White Irish Gypsy or Irish Traveller Roma Any other White background

Black background

Black British Black Caribbean Black African Any other Black background

	Black British	Black Caribbean	Black African	Any other Black background
Black background
Notes:

Asian background

Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background

	Asian British	Indian	Pakistani	Bangladeshi	Chinese	Any other Asian background
Asian background
Notes:

Mixed or multiple ethnic groups

White and Black Caribbean White and Black African White and Asian Any other mixed or multiple ethnic background

	White and Black Caribbean	White and Black African	White and Asian	Any other mixed or multiple ethnic background
Mixed or multiple ethnic groups
Notes:

Other ethnic group (please specify)

4000 characters remaining

Which of the following best describes your sexual orientation?

Heterosexual/Straight Homosexual/Gay/Lesbian Bisexual Other (please specify) Prefer not to say

Do you have any of the following?

A long-standing physical illness or condition A mental health condition A learning disability Blind or partially sighted Deaf or hearing impairment Other (please specify) Prefer not to say None of the above

Are you a veteran or serving member of the Armed Forces or the immediate family member or spouse of someone who is?

Yes No Prefer not to say

Thank you for completing our feedback survey

If your experience was very poor, we would appreciate you giving us some more information, so that we can fully understand and respond to your feedback, and make improvements in the most timely way. Please contact The Patient Advice and Liaison Service, via email dgn-tr.pals@nhs.net, or telephone 01322 428382

Friends and Family Test

We would like you to think about your recent visit...

Overall, how was your experience of our service?

Please can you tell us why you gave your answer or what we could have done better?

Can we share your comment publicly (for example, on our website or printed material such as posters)?

Are you able to answer some additional questions about your background to help us better understand your experience of care?

Are you:

How old are you?

How do you describe your gender?

Is your gender identity the same as the sex you were assigned at birth?

How do you describe your ethnic background?

White background

White background

Black background

Black background

Asian background

Asian background

Mixed or multiple ethnic groups

Mixed or multiple ethnic groups

Other ethnic group (please specify)

Which of the following best describes your sexual orientation?

Do you have any of the following?

Are you a veteran or serving member of the Armed Forces or the immediate family member or spouse of someone who is?

Submit

Thank you for completing our feedback survey