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Ronald Reagan Medical Center

Survey

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GOU Discharge Follow-up Survey

You were recently discharged from the Gonda Observation Unit at Ronald Reagan UCLA Medical Center. We would like to follow up to see how you are doing. Please take a few minutes to fill out this survey so that we can better serve you.

* Indicates required information

Please provide the following information to help us best serve you.

First Name *
Last Name *

1. *
Are you having any concerns related to your admission?
      
2. *
Did your discharge instructions answer all of your questions and concerns?
      
3. *
One of our goals is to provide excellent patient care; on a 1-5 scale, may I ask how your care was?
           
4.
Comments:
5. *
Was there anything that we could have done differently?
      
6.
Comments:
7. *
Would you like someone to call you back?
      
8.
If yes, please provide your contact information:
9.
Was there anyone in particular that you would like to acknowledge for the care they provided?
10. *
When were you discharged? (Exact dates are not required)