Please fill out the following evaluation form in regards to your family member’s recent stay at the ICU.

Which ICU was the patient stay on:

Your relationship to the patient:

Before this most recent event, was one of your immediate family members previously seen in the ICU?

Evaluation

Please rate the subjects on the left using one of the options to the right.

The courtesy, respect and compassion shown to your family member:

The interest the ICU staff displayed toward your needs:

The emotional support provided by the ICU staff:

The teamwork of the ICU staff while providing care to your family member:

The nurses’ communication to you about your family member’s conditions:

The doctor’s communication to you about your family member’s conditions:

The ICU staff’s communication to you about the care performed on your family member and the reason for the care:

The consistency of the information you heard from different staff members:

The willingness of the ICU staff to answer your questions:

Decisions about your family member's care:

Please tell us about your experience with the decision making process.

Did you feel supported during the decision making process?

Did you feel included in the decision making process?

We do great work, help us be even better.

Please help us become the best we can be. If you have any suggestions please provide them below. These submissions are completely confidential.

Do you have any suggestions on how to improve the care provided in the ICU?

Do you have any comments on things we are doing well?