ID# _________________

Date: ________________

™
PedsQL
Healthcare Satisfaction
Hematology/Oncology Module
Version 3.0

PARENT REPORT

DIRECTIONS

Please answer the following questions telling us how satisfied you are with the
care you, your child, and your family have received at the hospital from the staff.
Please tell us how happy you are with each item by circling:

1 if you are very dissatisfied

2 if you are dissatisfied
3 if you are neither satisfied nor dissatisfied
4 if you are satisfied
5 if you are very satisfied
How
There are no right or wrong answers.
If you do not understand a question, please ask for help.

satisfied are you with…

GENERAL SATISFACTION Neither
Very Satisfied nor Very
Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied
1. The overall care your child is receiving 1 2 3 4 5
2. How friendly and helpful the staff is 1 2 3 4 5
3. The way your child is treated at the
1 2 3 4 5
hospital

INFORMATION Neither
Very Satisfied nor Very
Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied
1. How much information was provided
to you about your child’s diagnosis 1 2 3 4 5

PedsQL 3.0 Healthcare Satisfaction Hematology/Oncology Module – Parents Copyright © 2002 J W Varni, Ph.D.
12/02 All rights reserved
 PedsQL 2

2. How much information was provided

to you about the treatment and 1 2 3 4 5
course of your child’s disease

3. How much information was provided

to you about the side effects of your 1 2 3 4 5
child’s treatment

4. How soon information was given to

1 2 3 4 5
you about your child’s test results

5. How often you are updated about

1 2 3 4 5
your child’s disease and health

INCLUSION OF FAMILY Neither

Very Satisfied nor Very
Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied
1. The sensitivity shown to your family
1 2 3 4 5
during your child’s treatment
2. The willingness to answer questions
1 2 3 4 5
that you and your family may have
3. The effort to include your family in
discussion of your child’s care and
1 2 3 4 5
other information about your child’s
disease
4. How much time the staff gave you to
ask any questions you may have had
1 2 3 4 5
about your child’s disease and
treatment

PedsQL 3.0 Healthcare Satisfaction Hematology/Oncology Module – Parents Copyright © 2002 J W Varni, Ph.D.
12/02 All rights reserved
 PedsQL 3
How satisfied are you with…
COMMUNICATION Neither
Very Satisfied nor Very
Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied
1. How well the staff explained your
child’s disease and treatment to your
1 2 3 4 5
child in a way that she/he could
understand
2. The time taken to explain your child’s
disease and treatment to you in a 1 2 3 4 5
way you could understand
3. How well the staff listens to you and
1 2 3 4 5
your concerns
4. The preparation provided for you
about what to expect during tests and 1 2 3 4 5
procedures
5. The preparation provided for your
child about what to expect during 1 2 3 4 5
tests and procedures

TECHNICAL SKILLS Neither

Very Satisfied nor Very
Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied
1. How well the staff responds to your
1 2 3 4 5
child’s needs
2. Efforts to keep your child comfortable
1 2 3 4 5
and as pain-free as possible

3. How quickly the staff responds to

1 2 3 4 5
your child’s nausea
4. How much time the staff took to help
you with your child coming back 1 2 3 4 5
home

EMOTIONAL NEEDS Neither

Very Satisfied nor Very
Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied
1. The amount of time given to your
child to play, talk about her/his 1 2 3 4 5
feelings, and any questions she/he
may have
2. The amount of time spent helping
1 2 3 4 5
your child with going back to school
3. The amount of time spent attending
1 2 3 4 5
to your child’s emotional needs
4. The amount of time spent attending
1 2 3 4 5
to your emotional needs
PedsQL 3.0 Healthcare Satisfaction Hematology/Oncology Module – Parents Copyright © 2002 J W Varni, Ph.D.
12/02 All rights reserved
 PedsQL 4

PedsQL 3.0 Healthcare Satisfaction Hematology/Oncology Module – Parents Copyright © 2002 J W Varni, Ph.D.
12/02 All rights reserved