Complaint / Comment Form	
Date:				
Do you wish to make a: (please tick ) 	Complaint			Comment		

Hospital 	Please tick	
St Nicholas Hospital 		
Campus for Ageing and Vitality 		
Royal Victoria Infirmary 		
St George’s Park 		
Hopewood Park 		
South Tyneside District General Hospital 		
Queen Elizabeth Hospital 		
Monkwearmouth Hospital 		
Northgate Hospital 		
Ferndene Hospital 		
Carleton Clinic		
Other (Please Specify) 		
Ward/ Department 			
Your Details 		
Name 			
Address 			
			
Postcode 			
Telephone 			
Made on behalf of: (please tick) 	Self 		Friend 		Relative (relationship) please state: Daughter			
Service User Details (If different from above) 		
Name 			
Address 			
			
Postcode 			
Telephone 			

Complaint / Comment Form (Side 1)
DETAILS	
Attach additional information if needed.	
Complaint / Comment Form (Side 2) continued… 
 What would you consider to be a satisfactory outcome? 
	
Signed: 		
Date: 		

Please forward to: Complaints Department, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, St Nicholas House, St Nicholas Hospital, Jubilee Road, Gosforth, Newcastle upon Tyne, NE3 3XT
If you are presently an in-patient within Trust Services or you complete this form whilst visiting the Trust, this form can be returned via the internal courier service, free of charge.   Please ask the nursing staff how this can be done. 

 

Equality and Diversity Monitoring Form 
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (the Trust) has a public duty to promote race equality, disability equality and gender equality. The Single Equality Bill extends equality legislation to fully cover the following issues 
• Race 	• Age 	
• Disability 	• Sexual Orientation 	
• Gender 	• Religion or Belief 	

The Trust as a responsive service provider wishes to monitor equality and diversity information provided by those making complaints. All the information we receive will be used and treated with the strictest confidence. Any information released will be anonymous with all names removed. 
There is no obligation to complete this section, but any information that you can provide will help us to provide a better service. 

A. Ethnicity 
Please note we are not asking about citizenship or nationality, but about the ethnic group to which you feel you belong. If you feel you are descended from more than one group, please tick the one you feel you most belong to, or choose the ‘Any other ethnic group’ option. 
A 	White 	British 		
B 	White 	Irish 		
C 	White 	Any other White background 		
D 	Mixed 	White and Black Caribbean 		
E 	Mixed 	White and Black African 		
F 	Mixed 	White and Asian 		
G 	Mixed 	Any other mixed background 		
H 	Asian or Asian British 	Indian 		
J 	Asian or Asian British 	Pakistani 		
K 	Asian or Asian British 	Bangladeshi 		
L 	Asian or Asian British 	Any other Asian background 		
M 	Black or Black British 	Caribbean 		
N 	Black or Black British 	African 		
P 	Black or Black British 	Any other Black background 		
R 	Other ethnic groups 	Chinese 		
S 	Other ethnic groups 	Any other ethnic group 		

B. Gender 

Male 						Female	

C. Disability 
The Disability Discrimination act (DDA) protects disabled people. The Act sets out the circumstances in which a person is ‘disabled’. It says you are disabled if you have: 
A mental or physical impairment that has an adverse effect on your ability to carry out normal day-to-day activities (meaning it has lasted 12 months, or is likely to last for 12 months or more) 
There are some special provisions, for example: 
If your disability has badly affected your ability to carry out normal day-to-day activities, but it doesn’t any more, it will still be counted as having that effect if it is likely to do so again 

If you have a progressive condition and it will badly affect your ability to carry out normal day-to-day activities in the future, it will be treated as having a bad effect on you now. 
Cancer, HIV infections, and multiple sclerosis are covered effectively from the point of diagnosis.  Past disabilities are covered. 

Taking this into consideration, do you consider yourself to have a disability? 

Yes 					No			

D. Sexual Orientation 

Heterosexual				Gay				Bisexual

I do not wish to disclose my sexual orientation 							

E. Religious Belief 
Religion/Belief 	√ 	
Atheism 		
Buddhism 		
Christianity 		
Hinduism 		
Islam 		
Jainism 		
Judaism 		
Sikhism 		
Other 		

I do not wish to disclose my religious belief