Q1) Why did you contact the supplier?

To submit a NHS prescription for:		Or for some other reason... please give reason(s) below:
Yourself Someone else Both

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             Q2) How do you normally contact your supplier?

by telephone

by fax

by post

by email

face to face

by the internet

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            Q3) How easy did you find it to contact them?

Not at all easy

Fairly easy

Very easy

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            Q4) If you have dealt with the supplier either by telephone, email or in person, based on your experience of this and other occasions, how would you rate them and the services listed below?

* Please tick one box for each aspect of the service listed below, to show how good or poor you think it is:
                                                   

ANSWERS
a) Were they polite and did they take the time to understand your needs?	0 1 2 3 4
b) Answering any queries you may have	0 1 2 3 4
c) Passing you on to someone who can advise	0 1 2 3 4
d) How would you describe their service?	0 1 2 3 4

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            Q5) If you had a prescription dispensed, did the supplier who supplied the appliance provide you with a written note of the supplier’s name, address & telephone number?                             

Yes

No

I don't know

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The next two questions are about occasions when the appliance was not available at the time requested. If this does not apply to you please go to question 8.

            Q6) If there has ever been an occasion when the appliance was not available straightaway (based on your experience of this and other occasions you have used this supplier), please answer the following:                                      

ANSWERS
a) Did you receive a written note of the appliance which is/was owed?	0 1 2
b) Were you informed when it is/was expected to become available?	0 1 2

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            Q7) If the appliance was not in stock from the supplier, or if they were not able to provide an appliance customisation on request:

ANSWERS
a) Were you asked to agree that they should refer the prescription to someone able to supply the appliance or appliance customisation?	0 1 2
b) Where you did not agree, did they provide the contact details of at least 2 other suppliers who were able to provide the appliance or appliance customisation?	0 1 2

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This question is about repeat prescriptions, if this does not apply to you please go to question 9.

            Q8) If you presented a repeat prescription, did the supplier:

ANSWERS
a) Check to see if you still needed the appliance?	0 1 2
b) Check that you were satisfied in using the appliance?	0 1 2
c) Check that you were not suffering from any problems with the appliance or your stoma treatment?	0 1 2

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            Q9) If the appliances you receive are customised in any way, how do you rate the overall quality of this service from your supplier?

Not at all satisfied

Not very satisfied

Fairly satisfied

Very satisfied

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            Q10) Some appliances may be delivered for patient convenience. Suppliers only have to deliver bulky packages, such as catheters. If your product is a bulky product, did the supplier offer to deliver the specified appliance to your home?

Yes

No

Not applicable

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            Q11) The following questions are about appliances where delivery should be offered ie bulky packages. If this doesn’t apply to you please go to question 12.

ANSWERS
a) Was the delivery prompt and at a time agreed with you?	0 1
b) Did the package display any writing or other markings which could indicate its content	0 1
c) Did the vehicle in which the package was delivered convey the nature of the contents	0 1
d) Did you receive a reasonable supply of supplementary items? (such as disposable wipes and disposal bags)	0 1

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            Q12) If the supplier believes it is appropriate to do so, they can offer you an Appliance Use Review (AUR)

ANSWERS
a) Have you ever been offered a review (AUR) by your supplier?	0 1
b) Have you ever been advised by your supplier that they cannot provide this service?	0 1
c) Did they give you contact details of at least two suppliers of appliances or pharmacies, who are able to arrange for the service to be provided?	0 1

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            Q13) If you have ever contacted the supplier’s telephone care line out of hours, are the following services provided?

ANSWERS
a) Either advice, or if not, the telephone number of NHS Direct or is their website address provided	0 1 2

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            Q14) Does the supplier provide the following?

ANSWERS
a) A practice leaflet containing information about their premises ie opening hours and access for disabled customers	0 1 2
b) Does this practice leaflet contains information about the NHS services that they provide	0 1 2

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            Q15) Taking everything into account - the staff, the information materials, contact options, quality and reliability of delivery and the overall service provided - how would you rate the supplier who sent you this questionnaire?

Excellent

Very Good

Good

Fair

Poor

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            Q16) If you have any comments about any of the questions above or how the service from this supplier could be improved, please let us know in the Text Area below:

* Insert here, if required, additional questions relating to healthcare service provision

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            Q17) If you have attended the premises of the supplier, how do you rate the following?

ANSWERS
a) Cleanliness of the premises	0 1 2 3 4
b) Suitability for the purpose	0 1 2 3 4

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            Q18) Have you ever visited the supplier’s premises?

Yes

No

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            Q19) How old are you?

16-19

20-24

25-34

35-44

45-54

55-64

65+

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            Q20) Are you?

Male

Female

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            Q21) Which of the following apply to you?

You have, or care for, children under 16.
You are a carer for someone with a longstanding illness or infirmity.
Neither

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