CRITICAL CARE FAMILY SATISFACTION SURVEY (CCFSS)

Date Completed ________________

Instructions:
Please have ONE family member complete the survey. Give your honest opinion for each statement on the
survey. CIRCLE one of the five answers that best describes how satisfied you were with the care that you
and your family member received while in the critical care unit. At the end of the survey, please comment on
any negative or positive experiences you may have had. After filling out the survey, please seal it in the
envelope provided and return it to the nurse or administrative partner.
General Questions
Your age:

18 24

25 34

35 59

60 or more

Number of days your loved one is/was in the critical care unit:
03
47
8 10
I am the patients:
Husband
Wife
Significant Other
Friend

Father
Mother
Brother
Sister

Son
Daughter
Uncle
Aunt

more than 10
Other __________
(please add)

Why is your family member in the critical care unit: _________________________________________

Very
Satisfied

Satisfied

Not
Certain

Not
Satisfied

Very
Dissatisfied

1. Honesty of the staff about my family members

condition..

2. Availability of the doctor to speak with me on a

regular basis...

3. Waiting time for results of tests and x-rays

4. Peace of mind in knowing my family members

nurse(s)

5. Ability to share in the care of my family member

6. Clear explanation of tests, procedures, and

treatments.

7. Promptness of the staff in responding to alarms

and requests for assistance..

8. Cleanliness and appearance of the waiting room

9. Support and encouragement given to me during

my family members stay in the critical care unit

10. Clear answers to my questions.

11. Quality of care given to my family member.

Form revised 12/3/03

Very
Satisfied

Satisfied

Not
Certain

Not
Satisfied

Very
Dissatisfied

12. Sharing in decisions regarding my family

members care on a regular basis

13. Nurses availability to speak with me every day

about my family members care

14. Sensitivity of the doctor(s) to my family

members needs..

15. Privacy provided for me and my family member

during our visits

16. Preparation for my family members transfer

from critical care..

17. Peacefulness of the waiting room.

18. Flexibility of visiting hours..

19. Noise level in the critical care unit

20. Sharing in discussions regarding my family

members recovery..

21. Effectiveness of control of my family members

pain

22. Effectiveness of control of my family members

shortness of breath.

23. Effectiveness of control of my family members

anxiety..

24. Effectiveness of control of my family members

depression

25. Support given to me by the pastoral care staff

and/or the chaplain.

26. Spiritual support given to me by other hospital

personnel...

27. In general, the meeting of my family members

needs

What else would you like us to know so we can take better care of our patients and their families?

Please feel free to name any individuals you feel are worthy of special recognition:

Form revised 12/3/03