NAME AND HEADQUARTERS OF HOSPITAL HEALTH INSTITUTION:
In order to ensure the best possible quality of treatment and care, we have prepared this survey which contains questions related to the systematicity and consistency of care that was provided to you, dignity and respect shown to you, your involvement in treatment, staff satisfaction and ultimately satisfaction with hygiene and cleanliness.
If you want to contribute to the quality of treatment and care, please express your observations and experiences during your stay in this department (institution) by answering the questions in the survey. The survey is anonymous.
Please mark one of the answers offered for each question that you think best suits your case.
The person filling out the survey:
Your age group:
less then 20 years21 - 40 years41 - 60 yearsmore then 60 years
lower educationhigh school educationcollegeuniversity degree
1. I was waiting to be admitted to the hospital for:
emergency receptionup to 1 month2-3 months4-6 months7-12 monthslonger then 12 months
2. The doctor informed me about my health condition:
not at allinsufficientlypartiallysufficientlyentirely
3. I was acquainted with the different treatment options for my condition:
4. The doctor treated me:
unkindlywith no interestcorrectlywith kindexceptionally kind
5. The nurses treated me:
6. The medical staff treated me:
less kind than to other patientsequal as to other patientsmore kind than to other patients
Please express your satisfaction or dissatisfaction on a scale of 1 to 5, where 1 indicates complete dissatisfaction and 5 indicates complete satisfaction.
7. Are you satisfied with the health service provided?
---1 - complete dissatisfaction2 - dissatisfaction3 - mediocre4 - contentment5 - complete contentment
8. Are you satisfied with the cleanliness of the hospital room and / or department?
9. Are you satisfied with the hygiene of the sanitary facilities?
10. Are you satisfied with the nutrition provided?
11. To protect Your rights, You will address:
---1. The head of the department2. The director of the hospital health facility3. Ministry of Health and Social Welfare4. Protection of Patients' Rights Association5. Croatian Medical Chamber6. Croatian Dental Chamber7. Media (journalists, television)9. I will not address anyone10. Someone else (enter in the blank field)