CITIZEN FEEDBACK FORM Service User's Name First Date of Feedback DD slash MM slash YYYY arrow_drop_down Feedback Taken By Wyville Home Care Supervisor Wyville Home Care SupervisorFeedback Provided By:Service UserService User's WifeService User's HusbandService User's PartnerService User's DaughterService User's Daughter in LawService User's SonService User's Son in LawService User's NieceService User's NephewService User's Grand ChildrenService User's MotherService User's FatherService User's BrotherService User's SisterService User's Sister in LawSocial WorkerDistrict NursesParamedicsOtherIf Other, Please Specify, Feedback Taken Over Face to Face Over the Phone Over the Email Received an Email Other Do the care staff approach you politely? Yes No Do the carers ask for your choice? Yes No Do the care staff communicate with you properly? Yes No Are the care staff wearing the PPE? (Mean, Surgical Face Mask, Disposable hand gloves and disposable apron) Yes No Do the care staff respect your privacy and dignity? Yes No Are carers wearing full uniform and ID? Yes No Are the care staff following correct manual handling? (Mean, are the care staff supporting you with correct moving and handling equipment?) Yes No Are the care staff supporting you to complete all task? Yes No Do the care staff assist you to manage your medication? Yes No Self-Administer Family Support Do you need any extra support(accompany, hosital appointments, shopping calls etc.)? Yes No Do you have any concerns to discuss? Yes No Are you happy with the service? Yes No How would you rate out care service? Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied Do you have any specific care staff who you wants to appreciate? So we will keep in our record and we will send them frequently? Yes No If Yes, please write the name,Feedback Comments
