Patient Feedback Declaration Form

You have agreed to manage the distribution of patient questionnaires for

Dr Sanja Besarovic (Hull & East Yorkshire Hospitals NHS Trust) INSTRUCTIONS Please distribute all 30 questionnaires in a random and unbiased way over a period of at least a week. Do not simply choose patients you like or those who you think will co-operate best; We suggest you select the first/last/ third etc. patient of every surgery, clinic or admission. This removes bias from the process. Please try not to be influenced by the doctor on who to choose. Explain to patients how to answer the questions and check that the patients have understood. Stress to the patient that their feedback is fully anonymous. A MINIMUM of 17 completed questionnaires are required in order for the doctors patient report to be released. ALL completed questionnaires must be returned IN 1 DELIVERY. This declaration form must be signed and returned to us with the completed questionnaires. Should you have any questions regarding the process please contact support@edgecumbe.co.uk or telephone 01179 258822.

Many thanks for your support Doctor 360 Support Team

As the appointed support colleague of the doctor named above I, ............................, confirm that the enclosed patient questionnaires were distributed in line with the instructions above. SIGNED: DATE:
Edgecumbe Consulting Group Ltd 2011

 Edgecumbe Consulting Group Ltd 2011