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Survey Submission

This page is only for Care Extenders volunteering in the Critical Care Unit (CCU), Emergency Room (ER), Medical Surgical (MED SURG), Oncology (ONCO), Orthopaedics (ORTHO), and Santa Monica Pediatrics (SMH-PEDS).  Please submit the support services survey on this electronic form:

Electronic Support Services Survey Submission - with bilingual questions on the reverse side

* Note - the survey was revised starting November 7th, 2012. If you have a survey without bilingual questions on the reverse side (see below), please email the Administrative Coordinator immediately (ce.adcoordinator@gmail.com).

The Support Services Quality Control Survey is an important tool to report information for the Santa Monica Hospital. The information is used on a weekly basis to address problem areas in the hospital's support services, such as environmental services, nutrition, transport, etc. Your help with filling out these surveys during every one of your volunteering shifts in the department is invaluable to the hospital and the level of care it provides to its patients. You will find blank copies of the Support Services Quality Control Surveys at the Arizona entrance of the Santa Monica Hospital. There is a grey box fixed to the wall approximately at eye level across the hall from the sign in computer. Please take one of these surveys every time you volunteer in the Critical Care Unit, Emergency Room, Medical Surgical, Oncology, Orthopaedics, or Pediatrics at Santa Monica. During your shift, kindly ask the charge nurse (or any nurse if the charge nurse is busy) which patients would be the best to interview. Kindly approach the patient when it is convenient for them (not undergoing a procedure or speaking with medical staff) and practice CICARE:

  • Connect with the patient,
  • Introduce yourself and your role,
  • Communicate to them that you would like to ask them some questions regarding the support services,
  • Ask if they have any questions or concerns and for their permission to do the survey,
  • Respond to their questions/concerns,
  • and Exit courteously
Please ask them if they have done the survey recently; if they have, thank them for their time and move onto a patient who has not done the survey recently. This will help us get feedback from more patients.  After your shift is over and you have completed the survey, please take the form home with you and enter the survey electronically with the link at the top of this page.

If you have any questions regarding the support services surveys, please contact the Administrative Coordinator at ce.adcoordinator@gmail.com.

Below is a blank copy of the survey for your reference:

Support Services Surveys Front Support Services Surveys Front

Click here to download the survey:

Blank Support Services Quality Control Survey (PDF, 52 KB)

 (Note: you do NOT have to print this out yourself, copies will be provided for you and this link is only for your reference only)