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Hospital Eye Donation Survey

In an ongoing effort to continue to improve the quality of our service, please take a moment to fill out our questionnaire about the service that we provide for your hospital.

Your Name:         Title:        

Hospital:              Floor/Unit:

1. Are you completing this survey in response to a specific case or as a feedback to our overall service to your hospital?  Specific case Overall service

        If in response to a specific case, please include patient initials and date of the referral (we are HIPAA exempt).

        Patient Initials:         Date of Service:

2. Did our staff return the initial call in a timely manner?                                                                   Yes No

3. Was the answering service professional?                                                                                       Yes No

4. Were your questions answered adequately?                                                                                   Yes No          

5. Do you think the needs of the family were met?                                                                              Yes No  

6. Was the Eye Bank staff/technician professional?                                                                            Yes No

7.  Did the Eye Bank keep the hospital well informed?                                                                       Yes No

8. Would you like an in-service on donation, the process, consent or any changes in the process? Yes No                                                                         

Please give us any other comments: