C-ICARE SURVEY

We want you to have the best experience possible. Please check the box "yes" or "no" next to each statement below to let us know how we are doing.

Did our team member:
 

Connect with you or your child by addressing you/your child as Mr./Mrs./Ms. or by the name you/your child prefers?
 
Yes
No
 
Introduce him/herself and their role?
 
Yes
No
 
Communicate to you what they were going to do, how long it would take and how it would impact you/your child?
 
Yes
No

Ask if you had any need, questions, or concerns?
Yes
No
Respond to your/your child's request and question in timely manner?
Yes
No
Exit courteously with an explanation of what will come next?
Yes
No
Please check which organ transplant you received:

Heart

Lung

Liver

Kidney

Small Bowel

Pancreas

Team member's name: 


Team member's position:

MD

RN/Coordinator

Administrative Assistant

Financial Counselor

Social Worker
 
Dietitian

Other
 
Location: 


 
Date: 

Comments: 

 

Thank you very much for taking the time to fill out this form!


UCLA Healthcare - Transplant Services
Last revised: June 16, 2008