Bereavement Care Program 
Satisfaction Survey

Thank you for letting us care for your loved one. Your feedback is very important to us and assists us with the continual improvement of our services. We ask you to focus on the role Hospice has played in the past year since the death of your loved one. Your participation in this effort is voluntary and will not affect any services you may receive from us in the future. We thank you in advance for taking the time to complete the survey.
1.How effective were the bereavement phone calls?(Required.)
Extremely Ineffective
Least Ineffective
Ineffective
Neither Ineffective or Effective
Effective
Very Effective
Extremely effective
2.How effective were the bereavement mailings you received  from Hospice?(Required.)
Extremely Ineffective
Very Ineffective
Ineffective
Neither Ineffective or Effective
Effective
Very Effective
Extremely Effective
3.Did you receive as much bereavement care and support as you wanted?(Required.)
No Support
Some Support
Minimal Support
Supportive
Good Support
Very Good Support
Excellent Support
4.Which bereavement support services did you utilize ?(Required.)
5.In the first year of grief, did our bereavement services assist you with the understanding grieving process?
N/a
Minimally
Some
Highly
6.How would you evaluate the total  bereavement program you received from hospice?(Required.)
Extremely Poor
Very Poor
Poor
Neither Poor or Good
Good
Very Good
Excellent
7.Who was the deceased?(Required.)
8.What is your age?(Required.)
9.Open textbox for suggestions and comments: