INOVA - RSS Live Form - rev.6.30.2021 Logo
  • Section 1

  • Page 1 - Consent

    Page 1 - Consent

  • Welcome to the Recipient Satisfaction Survey

    This survey is powered by

     

     

    This survey is voluntary, you can choose not to participate.

     

    Why are you being asked to participate in this survey?

    Candid feedback from patients helps to improve the quality of care provided by hospitals. Your participation in the MyLVAD Patient Satisfaction Survey will help the hospital that implanted your VAD or that follows you throughout your LVAD journey. Your answers to this survey help them monitor and improve their LVAD program.

     

    What will happen to the information that you provide?

    Information obtained from the survey will be coded with an identification number so that your responses can be tracked over time. That number will not be shared with anyone but MyLVAD staff members. The number will not be given to your LVAD hospital.  Your responses will be added to the responses of other LVAD patients and reports will be given to your hospital team so they can improve the quality of care provided in the future. Your information will also be provided to those doing LVAD research. NO information that identifies you will be provided to researchers.

    Again,

    • NO information that identifies you will be provided to your LVAD hospital;
    • At NO time will any information that identifies you be provided to researchers;
    • NO registration information provided to MyLVAD.com will be associated with your survey answers.


    To continue, we do need your consent to collect and use your survey answers. Please review the statements below and select the one you prefer.

  •  / /
  • I understand that this survey is voluntary and I do not have to participate. I have read the description of the survey and have been given enough information to feel comfortable making the decision whether or not to participate. My decision to participate is indicated below.

  • Page 2 - Who

    Page 2 - Who

  • You have indicated that you are not the VAD Recipient. If you are completing this survey for a VAD recipient please continue with the survey indicating the Recipient's Answers.

  • Page 3 - Who - Other

    Page 3 - Who - Other

  • Page 4 - Helper

    Page 4 - Helper

  • Page 5 - Helper Other

    Page 5 - Helper Other

  • Page 6 - Age

    Page 6 - Age

  • Page 7 - Communication Device

    Page 7 - Communication Device

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 8 - Communication Device - Other

    Page 8 - Communication Device - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 9 - Device - Owner

    Page 9 - Device - Owner

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 10 - Type of Heart Pump

    Page 10 - Type of Heart Pump

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 11 - Type of Heart Pump - Other

    Page 11 - Type of Heart Pump - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 12 - LVAD Only

    Page 12 - LVAD Only

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 13 - LVAD Only - Other

    Page 13 - LVAD Only - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 14 - RVAD Only

    Page 14 - RVAD Only

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 15 - RVAD Only - Other

    Page 15 - RVAD Only - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 16 - BiVAD/LVAD

    Page 16 - BiVAD/LVAD

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 17 - BiVAD/LVAD - Other

    Page 17 - BiVAD/LVAD - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 18 - BiVAD/RVAD

    Page 18 - BiVAD/RVAD

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 19 - BiVAD/RVAD - Other

    Page 19 - BiVAD/RVAD - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 20 - TAH

    Page 20 - TAH

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 21 - TAH - Other

    Page 21 - TAH - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 22 - Time on Device

    Page 22 - Time on Device

  • ***Answer Questions as if you are the RECIPIENT***

  • Section 2

  • Page 23 - Type of Visit

    Page 23 - Type of Visit

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 24 - Type of Visit - Other

    Page 24 - Type of Visit - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 25 - Date of Visit

    Page 25 - Date of Visit

  • ***Answer Questions as if you are the RECIPIENT***

  •  - -
  •  - -
  • Page 26 - Reason Hospital Stay

    Page 26 - Reason Hospital Stay

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 27- Reason Hospital Stay - Other

    Page 27- Reason Hospital Stay - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 28- Reason Outpatient Visit

    Page 28- Reason Outpatient Visit

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 29- Reason Outpatient Visit - Other

    Page 29- Reason Outpatient Visit - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 30- Reason Virtual/Online Visit

    Page 30- Reason Virtual/Online Visit

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 31- Reason Virtual/Online Visit - Other

    Page 31- Reason Virtual/Online Visit - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 32- Reason Telephone Contact

    Page 32- Reason Telephone Contact

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 33- Reason Telephone Contact - Other

    Page 33- Reason Telephone Contact - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 34- Reason Other Visit

    Page 34- Reason Other Visit

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 35- Reason Other Visit - Other

    Page 35- Reason Other Visit - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 36 - Core Team Satisfaction

    Page 36 - Core Team Satisfaction

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 37 - Ancillary Team Satisfaction

    Page 37 - Ancillary Team Satisfaction

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 38 - Cardiac Rehab

    Page 38 - Cardiac Rehab

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 39 - AC

    Page 39 - AC

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 40 - Team Comments

    Page 40 - Team Comments

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 41 - Discharge Summary

    Page 41 - Discharge Summary

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 42 - Discharge Summary - Other

    Page 42 - Discharge Summary - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 43 - Staff Additional Comments

    Page 43 - Staff Additional Comments

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 44 - Staff Additional Comments - Field

    Page 44 - Staff Additional Comments - Field

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 45 - Knowledge

    Page 45 - Knowledge

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 46 - Knowledge - Other

    Page 46 - Knowledge - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 47 - Knowledge - Additional Comments

    Page 47 - Knowledge - Additional Comments

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 48 - Knowledge - AC2

    Page 48 - Knowledge - AC2

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 49 - Caregiver

    Page 49 - Caregiver

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 50 - Caregiver AC

    Page 50 - Caregiver AC

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 51 - Caregiver - Other

    Page 51 - Caregiver - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 52 - Quality of Life

    Page 52 - Quality of Life

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 53 - Quality of Life Comments

    Page 53 - Quality of Life Comments

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 54 - Driving

    Page 54 - Driving

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 55 - Driving - Issue

    Page 55 - Driving - Issue

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 56 - Driving - Issue 2

    Page 56 - Driving - Issue 2

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 57 - Driving - Issue Description

    Page 57 - Driving - Issue Description

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 58 - Driving - Comments

    Page 58 - Driving - Comments

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 59 - Driving - Comments2

    Page 59 - Driving - Comments2

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 60 - EMS

    Page 60 - EMS

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 61 - EMS 2

    Page 61 - EMS 2

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 62 - EMS - Other

    Page 62 - EMS - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 63

    Page 63

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 64 - Driveline

    Page 64 - Driveline

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 65 - Driveline - Other

    Page 65 - Driveline - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 66 - Dressing Changes

    Page 66 - Dressing Changes

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 67 - Dressing Changes - Other

    Page 67 - Dressing Changes - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 68 - Dressing Change Comfort

    Page 68 - Dressing Change Comfort

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 69 - Dressing Change Comfort - Other

    Page 69 - Dressing Change Comfort - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 70 - Dressing Change Comfort - AC

    Page 70 - Dressing Change Comfort - AC

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 71 - Dressing Change Comfort - AC 2

    Page 71 - Dressing Change Comfort - AC 2

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 72 - Medication Organization

    Page 72 - Medication Organization

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 73 - Medication Organization - Other

    Page 73 - Medication Organization - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 74 - Anticoagulation

    Page 74 - Anticoagulation

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 75 - Anticoagulation - Other

    Page 75 - Anticoagulation - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 76 - Anticoagulation Changes

    Page 76 - Anticoagulation Changes

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 77 - Anticoagulation Changes - Other

    Page 77 - Anticoagulation Changes - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 78- INR Frequency

    Page 78- INR Frequency

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 79- INR Frequency - Other

    Page 79- INR Frequency - Other

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 80 - Home INR

    Page 80 - Home INR

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 81 - Home INR Concerns

    Page 81 - Home INR Concerns

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 82 - Home INR AC

    Page 82 - Home INR AC

  • ***Answer Questions as if you are the RECIPIENT***

  • Page 83 - Home INR AC 2

    Page 83 - Home INR AC 2

  • ***Answer Questions as if you are the RECIPIENT***

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