Juliet O Foundation – Feedback Form

Thank you for being a part of the Juliet O foundation’s mission to support patients during their recovery journey. Your feedback is invaluable in helping us improve and ensure we meet the needs of patients and hospitals. Please take a moment to complete this form.

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Date Hamper Received

How would you rate the presentation of your hamper? (1 = Poor, 10 = Excellent)

Selected Value: 0

How would you rate the quality of the items inside the hamper? 1 = Poor, 10 = Excellent)

Selected Value: 0

How would you rate the relevance of the items included for post-discharge recovery on a scale of 1-10? (1 = Not Relevant, 10 = Highly Relevant)

Selected Value: 0

What items did you find most useful in the hamper?

Were there any items you did not find useful? If so, please specify.

Are there any specific items you would like to see included in future hampers?

Would you recommend our service to other hospitals or patients?

• Yes
• No (Please specify why)

Are there any areas where you believe the Juliet O Foundation could improve?

future items =

Do you have any additional comments, suggestions, or feedback?

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