Demo - Live Template - rev.6.30.2021

Section 1
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.
Email*
example@example.com
Today's Date

MonthDayYear
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.
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Page 2 - Who
Who is the person completing this survey?*
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.
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Page 3 - Who - Other
You chose "other" - Tell us their relationship to the recipient.

Page 4 - Helper
Is anyone helping you complete this survey?
Who is the person helping you complete this survey?
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Page 5 - Helper Other
You chose "other" - Tell us who is helping you.

Page 6 - Age
Is the person who received the VAD 19 years or older?*
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Page 7 - Communication Device
***Answer Questions as if you are the RECIPIENT***
What kind of communication device are you using to provide information right now?*
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Page 8 - Communication Device - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us what type of communication device you are using.

Page 9 - Device - Owner
***Answer Questions as if you are the RECIPIENT***
Is the device owned by you or the hospital?*
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Page 10 - Type of Heart Pump
***Answer Questions as if you are the RECIPIENT***
What kind of heart pump do you have?*
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Page 11 - Type of Heart Pump - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us what kind of heart pump you have.

Page 12 - LVAD Only
***Answer Questions as if you are the RECIPIENT***
What is the brand name of your LVAD?
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Page 13 - LVAD Only - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us what is the brand of your LVAD?

Page 14 - RVAD Only
***Answer Questions as if you are the RECIPIENT***
What is the brand name of your RVAD?
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Page 15 - RVAD Only - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us what is the brand of your RVAD?

Page 16 - BiVAD/LVAD
***Answer Questions as if you are the RECIPIENT***
What is the brand - name of your LVAD?
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Page 17 - BiVAD/LVAD - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us what is the brand - name of your LVAD?

Page 18 - BiVAD/RVAD
***Answer Questions as if you are the RECIPIENT***
What is the brand - name of your RVAD?
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Page 19 - BiVAD/RVAD - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us what is the brand - name of your RVAD?

Page 20 - TAH
***Answer Questions as if you are the RECIPIENT***
What is the brand name of your Total Artificial Heart?
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Page 21 - TAH - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us what is the brand of your TAH?

Page 22 - Time on Device
***Answer Questions as if you are the RECIPIENT***
How long have you had your device (LVAD/RVAD/TAH)?*
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Section 2
Page 23 - Type of Visit
***Answer Questions as if you are the RECIPIENT***
What was your most recent visit with your VAD team?*
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Page 24 - Type of Visit - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us what type of visit you had with your VAD team.

Page 25 - Date of Visit
***Answer Questions as if you are the RECIPIENT***
Date of Hospital Discharge

MonthDayYear
Date of Visit

MonthDayYear
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Page 26 - Reason Hospital Stay
***Answer Questions as if you are the RECIPIENT***
What was the reason for your Hospital Stay?
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Page 27- Reason Hospital Stay - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us the reason for your hospital stay.

Page 28- Reason Outpatient Visit
***Answer Questions as if you are the RECIPIENT***
What was the reason for your Outpatient Visit?
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Page 29- Reason Outpatient Visit - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us the reason for your Outpatient Visit.

Page 30- Reason Virtual/Online Visit
***Answer Questions as if you are the RECIPIENT***
What was the reason for your Virtual/Online Visit?
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Page 31- Reason Virtual/Online Visit - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us the reason for your Virtual/Online Visit.

Page 32- Reason Telephone Contact
***Answer Questions as if you are the RECIPIENT***
What was the reason for your Telephone Contact?
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Page 33- Reason Telephone Contact - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us the reason for your Telephone Contact.

Page 34- Reason Other Visit
***Answer Questions as if you are the RECIPIENT***
What was the reason for your "Other" Visit?
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Page 35- Reason Other Visit - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us the reason for your "Other" Visit.

Page 36 - Core Team Satisfaction
***Answer Questions as if you are the RECIPIENT***
My DOCTORS explained the care of my VAD clearly.*
My VAD Coordinators were knowledgeable.*
My bedside caregivers were knowledgeable.
The outpatient staff/caregivers were knowledgeable.
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Page 37 - Ancillary Team Satisfaction
***Answer Questions as if you are the RECIPIENT***
Did a social worker assist you or your family?*
The assistance provided by the social worker was helpful.
Did a physical therapist assist you or your family?*
The assistance provided by the physical therapist was helpful.
Did an occupational therapist assist you or your family?*
The assistance provided by the occupational therapist was helpful.
Were you offered palliative care?*
The assistance provided by the palliative care recommendations were helpful.
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Page 38 - Cardiac Rehab
***Answer Questions as if you are the RECIPIENT***
Were you offered cardiac rehab?*
Did you go to cardiac rehab?
You answered no, why didn't you go to cardiac rehab?
You chose "other" - Tell us the reason you did not attend cardiac rehab.
The assistance provided by cardiac rehab was helpful.
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Page 39 - AC
***Answer Questions as if you are the RECIPIENT***
Do you have any additional comments about the hospital or staff?*
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Page 40 - Team Comments
***Answer Questions as if you are the RECIPIENT***
What would you like to tell us about the hospital caregivers or staff?
All comments are welcome! Tell us what was good or bad. Is there someone who stood out?

Page 41 - Discharge Summary
***Answer Questions as if you are the RECIPIENT***
Were you given a visit summary? (discharge paperwork or instructions for what to do after your visit)*
Did you read your visit summary?
The visit summary that was provided was helpful.
You answered no, why did you not read your visit summary?
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Page 42 - Discharge Summary - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us the reason you did not read your visit summary.

Page 43 - Staff Additional Comments
***Answer Questions as if you are the RECIPIENT***
Do you have any additional comments about the paperwork that was provided to you?
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Page 44 - Staff Additional Comments - Field
***Answer Questions as if you are the RECIPIENT***
Do you have any other comments about any of the paperwork provided to you?

Page 45 - Knowledge
***Answer Questions as if you are the RECIPIENT***
Do you know the dosages of all of your medication?*
Do you know the how to switch your power supplies?*
Do you know the how and when to charge your back-up equipment?*
Do you know who to call in an emergency?*
Do you currently feel overwhelmed by the equipment required for your care?*
Do you currently feel overwhelmed by the knowledge required for your care ?*
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Page 46 - Knowledge - Other
***Answer Questions as if you are the RECIPIENT***
You indicated that you may need some help with caring for yourself. Can you give us more information so we can find the best way to help?

Page 47 - Knowledge - Additional Comments
***Answer Questions as if you are the RECIPIENT***
Do you have any additional comments concerning your knowledge or self-care requirements?
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Page 48 - Knowledge - AC2
***Answer Questions as if you are the RECIPIENT***
What would you like to tell us about your knowledge or self-care requirements?

Page 49 - Caregiver
***Answer Questions as if you are the RECIPIENT***
Do you have a dedicated caregiver?*
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Page 50 - Caregiver AC
***Answer Questions as if you are the RECIPIENT***
Do you have any additional comments about your caregiver?
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Page 51 - Caregiver - Other
***Answer Questions as if you are the RECIPIENT***
What would you like to tell us about your caregiver?

Page 52 - Quality of Life
***Answer Questions as if you are the RECIPIENT***
I am happy with my Quality of Life?*
My Caregiver is happy with his/her Quality of Life?
is there anything that would make your quality of life better?*
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Page 53 - Quality of Life Comments
***Answer Questions as if you are the RECIPIENT***
What would make your Quality of Life better?

Page 54 - Driving
***Answer Questions as if you are the RECIPIENT***
Do you drive? *
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Page 55 - Driving - Issue
***Answer Questions as if you are the RECIPIENT***
Have you had any issues with your LVAD/RVAD/TAH while driving?
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Page 56 - Driving - Issue 2
***Answer Questions as if you are the RECIPIENT***
Would you be willing to tell us about your driving issue?
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Page 57 - Driving - Issue Description
***Answer Questions as if you are the RECIPIENT***
What would you like to tell us about your driving issue?

Page 58 - Driving - Comments
***Answer Questions as if you are the RECIPIENT***
Do you have any additional comments about driving?
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Page 59 - Driving - Comments2
***Answer Questions as if you are the RECIPIENT***
What additional comments do you have about driving?

Page 60 - EMS
***Answer Questions as if you are the RECIPIENT***
Have you had to call Emergency Medical Services (EMS) for assistance since your last visit?*
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Page 61 - EMS 2
***Answer Questions as if you are the RECIPIENT***
Did you call because of problems with your pump?
Did the Emergency Medical Services team know what to do to help you?
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Page 62 - EMS - Other
***Answer Questions as if you are the RECIPIENT***
Do you have any additional comments about your interactions with Emergency Services?
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Page 63
***Answer Questions as if you are the RECIPIENT***
Do you have any additional comments about your interactions with Emergency Services?

Page 64 - Driveline
***Answer Questions as if you are the RECIPIENT***
Where is your driveline site? Circle where your driveline site is located.*
Would you consider yourself?*
Are you happy with your driveline location?*
What would you change about your driveline location?
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Page 65 - Driveline - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us what you would change about your driveline location.

Page 66 - Dressing Changes
***Answer Questions as if you are the RECIPIENT***
Who Changes your driveline dressing?*
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Page 67 - Dressing Changes - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us who changes your driveline dressing.

Page 68 - Dressing Change Comfort
***Answer Questions as if you are the RECIPIENT***
The person who changes my driveline dressing feels comfortable with the procedure?*
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Page 69 - Dressing Change Comfort - Other
***Answer Questions as if you are the RECIPIENT***
You indicated that the person who changes your driveline dressing is may need some assistance. Can you tell us why they are uncomfortable with changing your driveline dressing?

Page 70 - Dressing Change Comfort - AC
***Answer Questions as if you are the RECIPIENT***
Do you have any additional comments about driveline or wound care?
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Page 71 - Dressing Change Comfort - AC 2
***Answer Questions as if you are the RECIPIENT***
What would you like to tell us about driveline or wound care?

Page 72 - Medication Organization
***Answer Questions as if you are the RECIPIENT***
Who keeps track of your medication?*
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Page 73 - Medication Organization - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other" - Tell us who who keeps track of your medication.

Page 74 - Anticoagulation
***Answer Questions as if you are the RECIPIENT***
What medications do you take for anticoagulation (blood thinners)?*
Do you take Aspirin?*
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Page 75 - Anticoagulation - Other
***Answer Questions as if you are the RECIPIENT***
You chose other, can you tell us what medication you take for anticoagulation (blood thinner)?

Page 76 - Anticoagulation Changes
***Answer Questions as if you are the RECIPIENT***
Who makes changes to your anticoagulation (warfarin) dosages?*
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Page 77 - Anticoagulation Changes - Other
***Answer Questions as if you are the RECIPIENT***
You chose "other". Can you tell us who makes changes to your anticoagulation (warfarin) dosages?

Page 78- INR Frequency
***Answer Questions as if you are the RECIPIENT***
How often do you routinely check your INR (when your levels are optimal)?*
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Page 79- INR Frequency - Other
***Answer Questions as if you are the RECIPIENT***
You chose other, can you tell us how often you routinely check your INR (when your levels are optimal)?

Page 80 - Home INR
***Answer Questions as if you are the RECIPIENT***
Do you check your INR at home?*
Are you comfortable checking your INR at home?
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Page 81 - Home INR Concerns
***Answer Questions as if you are the RECIPIENT***
You chose no, can you tell us your concerns?

Page 82 - Home INR AC
***Answer Questions as if you are the RECIPIENT***
Do you have any additional comments about your Medication, Anticoagulation, or INR Management?
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Page 83 - Home INR AC 2
***Answer Questions as if you are the RECIPIENT***
What would you like to tell us about your Medication, Anticoagulation or INR management?

Thank you for taking the time to complete the survey!

Please choose submit so your survey answers are saved.
Thank you for your consideration! If you change your mind this survey will be available online at any time.

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Section 1

Page 1 - Consent

Page 2 - Who

Page 3 - Who - Other

Page 4 - Helper

Page 5 - Helper Other

Page 6 - Age

Page 7 - Communication Device

Page 8 - Communication Device - Other

Page 9 - Device - Owner

Page 10 - Type of Heart Pump

Page 11 - Type of Heart Pump - Other

Page 12 - LVAD Only

Page 13 - LVAD Only - Other

Page 14 - RVAD Only

Page 15 - RVAD Only - Other

Page 16 - BiVAD/LVAD

Page 17 - BiVAD/LVAD - Other

Page 18 - BiVAD/RVAD

Page 19 - BiVAD/RVAD - Other

Page 20 - TAH

Page 21 - TAH - Other

Page 22 - Time on Device

Section 2

Page 23 - Type of Visit

Page 24 - Type of Visit - Other

Page 25 - Date of Visit

Page 26 - Reason Hospital Stay

Page 27- Reason Hospital Stay - Other

Page 28- Reason Outpatient Visit

Page 29- Reason Outpatient Visit - Other

Page 30- Reason Virtual/Online Visit

Page 31- Reason Virtual/Online Visit - Other

Page 32- Reason Telephone Contact

Page 33- Reason Telephone Contact - Other

Page 34- Reason Other Visit

Page 35- Reason Other Visit - Other

Page 36 - Core Team Satisfaction

Page 37 - Ancillary Team Satisfaction

Page 38 - Cardiac Rehab

Page 39 - AC

Page 40 - Team Comments

Page 41 - Discharge Summary

Page 42 - Discharge Summary - Other

Page 43 - Staff Additional Comments

Page 44 - Staff Additional Comments - Field

Page 45 - Knowledge

Page 46 - Knowledge - Other

Page 47 - Knowledge - Additional Comments

Page 48 - Knowledge - AC2

Page 49 - Caregiver

Page 50 - Caregiver AC

Page 51 - Caregiver - Other

Page 52 - Quality of Life

Page 53 - Quality of Life Comments

Page 54 - Driving

Page 55 - Driving - Issue

Page 56 - Driving - Issue 2

Page 57 - Driving - Issue Description

Page 58 - Driving - Comments

Page 59 - Driving - Comments2

Page 60 - EMS

Page 61 - EMS 2

Page 62 - EMS - Other

Page 63

Page 64 - Driveline

Page 65 - Driveline - Other

Page 66 - Dressing Changes

Page 67 - Dressing Changes - Other

Page 68 - Dressing Change Comfort

Page 69 - Dressing Change Comfort - Other

Page 70 - Dressing Change Comfort - AC

Page 71 - Dressing Change Comfort - AC 2

Page 72 - Medication Organization

Page 73 - Medication Organization - Other

Page 74 - Anticoagulation

Page 75 - Anticoagulation - Other

Page 76 - Anticoagulation Changes

Page 77 - Anticoagulation Changes - Other

Page 78- INR Frequency