Please tell us the approximate date of your hospitalization. (Month/Year)*

-- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / -- 2004 2003 2002 2001 2000 1999 1998 1997

What was the primary reason for your hospitalization?

For how many days were you hospitalized?*

If you recall, please indicate which unit you were in for most of your hospital stay. (Check all that apply.)

Emergency Room or Trauma

Outpatient Care

Inpatient - Acute Care Psychiatric Unit

Inpatient - Intensive Care Unit or other Emergency Critical Care Unit

Inpatient - Labor and Delivery Unit

Inpatient - Medical Surgical Unit

Other, please specify:

Were there always enough nurses to meet your needs in the unit?

Yes No --

If your answer was no, do you feel that not having enough nurses affected the quality of care you received?

Yes No --

Please describe your hospital experience in as much detail as possible.

What is your gender?

How old are you?

In what state do you live?*

-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY -- GU PR VI -- AB BC MB NB NF NS NT ON PE PQ SK YT

Can we contact you for additional information about your experience?*

-- Yes No

If yes, please provide a telephone number or email address that we can use to reach you?

Phone

Email