Example Phase 2 Survey by TEC Cymru

How did it go? Sut aeth e?

For data protection purposes, please do not enter any personal details on this form such as your name, or other people's names. Er mwyn diogelu data, peidiwch â mewnbynnu unrhyw fanylion fel eich enw neu enwau pobl arall ar y ffurflen hon.

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* 1. Please tick the 'yes' box if you are completing this survey on behalf of the patient (e.g., as a parent or carer)

Yes, I am completing this survey on behalf of the patient

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* 2. Please rate the quality of your video consultation Rhowch sgôr i ansawdd eich galwad fideo

Poor Gwael

Okay Iawn

Good Da

Very Good Da iawn

Excellent Ardderchog

Poor Gwael

Okay Iawn

Good Da

Very Good Da iawn

Excellent Ardderchog

Any comments?
e.g., what worked well, or not so well?

Unrhyw sylwadau?

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* 3. What device did you use for your video consultation today? Pa ddyfais wnaethoch chi ei defnyddio?

	Type of phone Math ffon	Type of tablet/iPad Math tabled	Type of laptop Math clyniadur	Type of computer Math cyfrifiadur
Type of device Math dyfais	Type of device Math dyfais Type of phone Math ffon menu	Type of device Math dyfais Type of tablet/iPad Math tabled menu	Type of device Math dyfais Type of laptop Math clyniadur menu	Type of device Math dyfais Type of computer Math cyfrifiadur menu

Other (please specify)

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* 4. Did you experience any difficulties with your video consultation today? Gwelwch chi unrhyw anawsterau gydag eich ymgynghoriad fideo heddiw?

	A lot llawer	Some Rhywfaint	A little Ychydig	Not at all Dim	N/A
Difficulties with a device Anawsterau Gyda dyfais	Difficulties with a device Anawsterau Gyda dyfais A lot llawer	Difficulties with a device Anawsterau Gyda dyfais Some Rhywfaint	Difficulties with a device Anawsterau Gyda dyfais A little Ychydig	Difficulties with a device Anawsterau Gyda dyfais Not at all Dim	Difficulties with a device Anawsterau Gyda dyfais N/A
Difficulties with Internet connection Anawsterau gyda chysylltiad rhyngrwyd	Difficulties with Internet connection Anawsterau gyda chysylltiad rhyngrwyd A lot llawer	Difficulties with Internet connection Anawsterau gyda chysylltiad rhyngrwyd Some Rhywfaint	Difficulties with Internet connection Anawsterau gyda chysylltiad rhyngrwyd A little Ychydig	Difficulties with Internet connection Anawsterau gyda chysylltiad rhyngrwyd Not at all Dim	Difficulties with Internet connection Anawsterau gyda chysylltiad rhyngrwyd N/A
Difficulties with video/picture Anawsterau gyda llun/ fideo	Difficulties with video/picture Anawsterau gyda llun/ fideo A lot llawer	Difficulties with video/picture Anawsterau gyda llun/ fideo Some Rhywfaint	Difficulties with video/picture Anawsterau gyda llun/ fideo A little Ychydig	Difficulties with video/picture Anawsterau gyda llun/ fideo Not at all Dim	Difficulties with video/picture Anawsterau gyda llun/ fideo N/A
Difficulties with audio/sound Anawsterau gyda sain	Difficulties with audio/sound Anawsterau gyda sain A lot llawer	Difficulties with audio/sound Anawsterau gyda sain Some Rhywfaint	Difficulties with audio/sound Anawsterau gyda sain A little Ychydig	Difficulties with audio/sound Anawsterau gyda sain Not at all Dim	Difficulties with audio/sound Anawsterau gyda sain N/A
Difficulties with privacy or a safe space Anawsteru gyda diogelwch neu pbeifatrwydd	Difficulties with privacy or a safe space Anawsteru gyda diogelwch neu pbeifatrwydd A lot llawer	Difficulties with privacy or a safe space Anawsteru gyda diogelwch neu pbeifatrwydd Some Rhywfaint	Difficulties with privacy or a safe space Anawsteru gyda diogelwch neu pbeifatrwydd A little Ychydig	Difficulties with privacy or a safe space Anawsteru gyda diogelwch neu pbeifatrwydd Not at all Dim	Difficulties with privacy or a safe space Anawsteru gyda diogelwch neu pbeifatrwydd N/A
Lack of confidence using video calls Diffyg hyder gyda defnydd fideo	Lack of confidence using video calls Diffyg hyder gyda defnydd fideo A lot llawer	Lack of confidence using video calls Diffyg hyder gyda defnydd fideo Some Rhywfaint	Lack of confidence using video calls Diffyg hyder gyda defnydd fideo A little Ychydig	Lack of confidence using video calls Diffyg hyder gyda defnydd fideo Not at all Dim	Lack of confidence using video calls Diffyg hyder gyda defnydd fideo N/A
Not suitable for clinical needs Anaddas am anghenion clinigol	Not suitable for clinical needs Anaddas am anghenion clinigol A lot llawer	Not suitable for clinical needs Anaddas am anghenion clinigol Some Rhywfaint	Not suitable for clinical needs Anaddas am anghenion clinigol A little Ychydig	Not suitable for clinical needs Anaddas am anghenion clinigol Not at all Dim	Not suitable for clinical needs Anaddas am anghenion clinigol N/A
Prefer face to face or telephone Mae'n well gen i wyneb yn wyneb neu dros y ffôn	Prefer face to face or telephone Mae'n well gen i wyneb yn wyneb neu dros y ffôn A lot llawer	Prefer face to face or telephone Mae'n well gen i wyneb yn wyneb neu dros y ffôn Some Rhywfaint	Prefer face to face or telephone Mae'n well gen i wyneb yn wyneb neu dros y ffôn A little Ychydig	Prefer face to face or telephone Mae'n well gen i wyneb yn wyneb neu dros y ffôn Not at all Dim	Prefer face to face or telephone Mae'n well gen i wyneb yn wyneb neu dros y ffôn N/A

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* 5. How did your video consultation benefit you today? Sut aeth yr ymgynghoriad fideo buddio chi heddiw?

	Very beneficial Buddiol iawn	Beneficial Buddiol	Quite beneficial Eithaf Buddiol	Not beneficial Dim yn Buddies	Not at all beneficial Dim yn Buddiol o gwbl	N/A
Saved time & preparation Arbed Amser a Pharatoi	Saved time & preparation Arbed Amser a Pharatoi Very beneficial Buddiol iawn	Saved time & preparation Arbed Amser a Pharatoi Beneficial Buddiol	Saved time & preparation Arbed Amser a Pharatoi Quite beneficial Eithaf Buddiol	Saved time & preparation Arbed Amser a Pharatoi Not beneficial Dim yn Buddies	Saved time & preparation Arbed Amser a Pharatoi Not at all beneficial Dim yn Buddiol o gwbl	Saved time & preparation Arbed Amser a Pharatoi N/A
Saved travel & parking Arbed teithio	Saved travel & parking Arbed teithio Very beneficial Buddiol iawn	Saved travel & parking Arbed teithio Beneficial Buddiol	Saved travel & parking Arbed teithio Quite beneficial Eithaf Buddiol	Saved travel & parking Arbed teithio Not beneficial Dim yn Buddies	Saved travel & parking Arbed teithio Not at all beneficial Dim yn Buddiol o gwbl	Saved travel & parking Arbed teithio N/A
Saved the environment & co2 emissions Arbed yr amgylchedd ac allbwn co2	Saved the environment & co2 emissions Arbed yr amgylchedd ac allbwn co2 Very beneficial Buddiol iawn	Saved the environment & co2 emissions Arbed yr amgylchedd ac allbwn co2 Beneficial Buddiol	Saved the environment & co2 emissions Arbed yr amgylchedd ac allbwn co2 Quite beneficial Eithaf Buddiol	Saved the environment & co2 emissions Arbed yr amgylchedd ac allbwn co2 Not beneficial Dim yn Buddies	Saved the environment & co2 emissions Arbed yr amgylchedd ac allbwn co2 Not at all beneficial Dim yn Buddiol o gwbl	Saved the environment & co2 emissions Arbed yr amgylchedd ac allbwn co2 N/A
Saved taking time off school, work or other commitments Arbed amser o waith, ysgol neu ymrwymiadau	Saved taking time off school, work or other commitments Arbed amser o waith, ysgol neu ymrwymiadau Very beneficial Buddiol iawn	Saved taking time off school, work or other commitments Arbed amser o waith, ysgol neu ymrwymiadau Beneficial Buddiol	Saved taking time off school, work or other commitments Arbed amser o waith, ysgol neu ymrwymiadau Quite beneficial Eithaf Buddiol	Saved taking time off school, work or other commitments Arbed amser o waith, ysgol neu ymrwymiadau Not beneficial Dim yn Buddies	Saved taking time off school, work or other commitments Arbed amser o waith, ysgol neu ymrwymiadau Not at all beneficial Dim yn Buddiol o gwbl	Saved taking time off school, work or other commitments Arbed amser o waith, ysgol neu ymrwymiadau N/A
Saved money e.g., childcare, travel Arbed arian am ofal plant/ teithio	Saved money e.g., childcare, travel Arbed arian am ofal plant/ teithio Very beneficial Buddiol iawn	Saved money e.g., childcare, travel Arbed arian am ofal plant/ teithio Beneficial Buddiol	Saved money e.g., childcare, travel Arbed arian am ofal plant/ teithio Quite beneficial Eithaf Buddiol	Saved money e.g., childcare, travel Arbed arian am ofal plant/ teithio Not beneficial Dim yn Buddies	Saved money e.g., childcare, travel Arbed arian am ofal plant/ teithio Not at all beneficial Dim yn Buddiol o gwbl	Saved money e.g., childcare, travel Arbed arian am ofal plant/ teithio N/A
Improved access to care & waiting times Gwella mynediad i ofal ac amser aros	Improved access to care & waiting times Gwella mynediad i ofal ac amser aros Very beneficial Buddiol iawn	Improved access to care & waiting times Gwella mynediad i ofal ac amser aros Beneficial Buddiol	Improved access to care & waiting times Gwella mynediad i ofal ac amser aros Quite beneficial Eithaf Buddiol	Improved access to care & waiting times Gwella mynediad i ofal ac amser aros Not beneficial Dim yn Buddies	Improved access to care & waiting times Gwella mynediad i ofal ac amser aros Not at all beneficial Dim yn Buddiol o gwbl	Improved access to care & waiting times Gwella mynediad i ofal ac amser aros N/A
Improved convenience e.g., staying at home Gwella hwylustod e.e. aros adref	Improved convenience e.g., staying at home Gwella hwylustod e.e. aros adref Very beneficial Buddiol iawn	Improved convenience e.g., staying at home Gwella hwylustod e.e. aros adref Beneficial Buddiol	Improved convenience e.g., staying at home Gwella hwylustod e.e. aros adref Quite beneficial Eithaf Buddiol	Improved convenience e.g., staying at home Gwella hwylustod e.e. aros adref Not beneficial Dim yn Buddies	Improved convenience e.g., staying at home Gwella hwylustod e.e. aros adref Not at all beneficial Dim yn Buddiol o gwbl	Improved convenience e.g., staying at home Gwella hwylustod e.e. aros adref N/A
Improved family involvement & support Gwella cyfranogiad a chymorth teulu	Improved family involvement & support Gwella cyfranogiad a chymorth teulu Very beneficial Buddiol iawn	Improved family involvement & support Gwella cyfranogiad a chymorth teulu Beneficial Buddiol	Improved family involvement & support Gwella cyfranogiad a chymorth teulu Quite beneficial Eithaf Buddiol	Improved family involvement & support Gwella cyfranogiad a chymorth teulu Not beneficial Dim yn Buddies	Improved family involvement & support Gwella cyfranogiad a chymorth teulu Not at all beneficial Dim yn Buddiol o gwbl	Improved family involvement & support Gwella cyfranogiad a chymorth teulu N/A
Lowered rates of infection risk Lleihau cyfraddau haint	Lowered rates of infection risk Lleihau cyfraddau haint Very beneficial Buddiol iawn	Lowered rates of infection risk Lleihau cyfraddau haint Beneficial Buddiol	Lowered rates of infection risk Lleihau cyfraddau haint Quite beneficial Eithaf Buddiol	Lowered rates of infection risk Lleihau cyfraddau haint Not beneficial Dim yn Buddies	Lowered rates of infection risk Lleihau cyfraddau haint Not at all beneficial Dim yn Buddiol o gwbl	Lowered rates of infection risk Lleihau cyfraddau haint N/A
Lowered stress and anxiety Lleihau straen a phryder	Lowered stress and anxiety Lleihau straen a phryder Very beneficial Buddiol iawn	Lowered stress and anxiety Lleihau straen a phryder Beneficial Buddiol	Lowered stress and anxiety Lleihau straen a phryder Quite beneficial Eithaf Buddiol	Lowered stress and anxiety Lleihau straen a phryder Not beneficial Dim yn Buddies	Lowered stress and anxiety Lleihau straen a phryder Not at all beneficial Dim yn Buddiol o gwbl	Lowered stress and anxiety Lleihau straen a phryder N/A

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* 6. How many times have you used video for a health or social care consultation, and would you use it again? Sawl gwaith ydych chi wedi defnyddio fideo am ymgynghoriad iechyd neu ofal iechyd, a byddwch chi’n defnyddio eto?

	How many times have you used a video consultation? Sawl gwaith ydych chi wedi ei defnyddio?	Would you like to use video consultation again? Byddwch chi’n ei defnyddio eto?
Video Consultation Use Defnydd fideo	Video Consultation Use Defnydd fideo How many times have you used a video consultation? Sawl gwaith ydych chi wedi ei defnyddio? menu	Video Consultation Use Defnydd fideo Would you like to use video consultation again? Byddwch chi’n ei defnyddio eto? menu

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* 7. What was your video consultation related to today? Beth oedd eich ymgynghoriad fideo yn ynghylch heddiw?

First time appointment
Awyntiad gyntaf

Review of my health and/or results
Adolygiad iechyd/ canlyniadau

Therapy or treatment session
Therapi neu sesiwn triniaeth

Advice & support
Cymorth neu gyngor

Final appointment & discharge
Apwyntiad olaf neu ryddhad

Other (please specify)

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* 8. Do you feel that this video consultation prevented you needing a face-to-face appointment?

(In other words, did you NOT need to attend in-person after this video for this appointment needs only)

Wnaeth yr ymgynghoriad fideo osgoi’r angen i’r claf gael apwyntiad wyneb i wyneb?

Yes le

No na

I don't know ansicr

Please describe this in more detail if you wish:
Disgrifiwch yn fanylder os hoffwch

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* 9. For your video consultation today, what type of healthcare speciality and professional did you see? Am eich ymgynghoriad fideo heddiw, pa fath o arbenigwr a phroffesiwn gwelwch chi?

	Health Condition Speciality Arbenigrwydd cyflwr iechyd	Professional Phroffesiwn
Speciality & Professional Arbenigwr a Phroffesiwn	Speciality & Professional Arbenigwr a Phroffesiwn Health Condition Speciality Arbenigrwydd cyflwr iechyd menu	Speciality & Professional Arbenigwr a Phroffesiwn Professional Phroffesiwn menu

Please state the health-related reason for your video consultation today?

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* 10. Whose choice was it to have a video consultation today? Dewis pwy oedd cael ymgynghoriad fideo heddiw?

I (the patient/or family) was given the choice of consultation, and I opted for a video consultation
Derbyniais i, y claf, y dewis i dderbyn ymgynghoriad fideo, ac fe dywysais i.

I was informed by my service that my consultation would be via video
Cefais wybod bydd yr ymgynghoriad trwy fideo.

Video consultation is the only option available
Roedd ymgynghoriad fideo yn yr unig opsiwn

I don't know
Ansicr

Other (please specify)

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* 11. How long would it typically take you to travel from your home to your consultation? (one way) Pa mor hir fyddai hi'n cymryd i chi deithio i'ch apwyntiad fel arfer?

Hours/Minutes
Horiau/ munudau

Miles (if known)
Milltiroedd (os yw’n hysbys)

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* 12. Which Health Board Region are you in? O ba Ranbarth Bwrdd Iechyd ydych chi’n dod?

Aneurin Bevan University Health Board

Betsi Cadwaladr University Health Board

Cardiff & Vale University Health Board

Cwm Taf Morgannwg University Health Board

Hywel Dda University Health Board

Powys Teaching Health Board

Swansea Bay University Health Board

Velindre Cancer Centre

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* 13. What is your local area/authority? Beth yw eich ardal / awdurdod lleol?

	Local Area / Authority	Type of Area
Local Area & Type	Local Area & Type Local Area / Authority menu	Local Area & Type Type of Area menu

Other (please specify)

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* 14. How would the patient describe themselves? Sut yw’r claf yn disgrifio ei hun?

	Age Old	Gender Rhyw	Ethnicity Ethnigrwydd	Household Income Incwm cartref	Disability Anabledd
Demographics Demograffeg	Demographics Demograffeg Age Old menu	Demographics Demograffeg Gender Rhyw menu	Demographics Demograffeg Ethnicity Ethnigrwydd menu	Demographics Demograffeg Household Income Incwm cartref menu	Demographics Demograffeg Disability Anabledd menu

In your given personal circumstances, is there anything (e.g., extra support) that would help (now or in the future) whilst using VC?

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* 15. As a result of your Video Consultation today, do you (or the patient) feel you are: Fel ganlyniad i'ch ymweliad heddiw, a ydych chi'n teimlo eich bod chin

	Much more Llawer mwy	More Mwy	Same or Less Yr un neu lai	N/A
Able to cope with life Medru ymdopi gyda bywyd	Able to cope with life Medru ymdopi gyda bywyd Much more Llawer mwy	Able to cope with life Medru ymdopi gyda bywyd More Mwy	Able to cope with life Medru ymdopi gyda bywyd Same or Less Yr un neu lai	Able to cope with life Medru ymdopi gyda bywyd N/A
Able to understand your illness Medru deall eich salwch	Able to understand your illness Medru deall eich salwch Much more Llawer mwy	Able to understand your illness Medru deall eich salwch More Mwy	Able to understand your illness Medru deall eich salwch Same or Less Yr un neu lai	Able to understand your illness Medru deall eich salwch N/A
Able to cope with your illness Medru ymdopi a'ch salwch	Able to cope with your illness Medru ymdopi a'ch salwch Much more Llawer mwy	Able to cope with your illness Medru ymdopi a'ch salwch More Mwy	Able to cope with your illness Medru ymdopi a'ch salwch Same or Less Yr un neu lai	Able to cope with your illness Medru ymdopi a'ch salwch N/A
Able to keep yourself healthy Medru cadw'ch hun yn iach	Able to keep yourself healthy Medru cadw'ch hun yn iach Much more Llawer mwy	Able to keep yourself healthy Medru cadw'ch hun yn iach More Mwy	Able to keep yourself healthy Medru cadw'ch hun yn iach Same or Less Yr un neu lai	Able to keep yourself healthy Medru cadw'ch hun yn iach N/A
Confident about your health Hyderus ynglun a'ch iechyd	Confident about your health Hyderus ynglun a'ch iechyd Much more Llawer mwy	Confident about your health Hyderus ynglun a'ch iechyd More Mwy	Confident about your health Hyderus ynglun a'ch iechyd Same or Less Yr un neu lai	Confident about your health Hyderus ynglun a'ch iechyd N/A
Able to help yourself Media help eich hunain	Able to help yourself Media help eich hunain Much more Llawer mwy	Able to help yourself Media help eich hunain More Mwy	Able to help yourself Media help eich hunain Same or Less Yr un neu lai	Able to help yourself Media help eich hunain N/A

Other (please specify)

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* 16. Any other comments, questions or concerns?
Unrhyw sylwadau, cwesitynau neu bryderon eraill?

For example:
How could your experience of video consulting today been improved?
What additional support would have helped?

By submitting this survey I provide full consent for the data provided to be used anonymously in publications and presentations by the TEC Cymru team working in the NHS.

Example Phase 2 Survey by TEC Cymru

How did it go? Sut aeth e?

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* 1. Please tick the 'yes' box if you are completing this survey on behalf of the patient (e.g., as a parent or carer)

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* 2. Please rate the quality of your video consultation Rhowch sgôr i ansawdd eich galwad fideo

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* 3. What device did you use for your video consultation today? Pa ddyfais wnaethoch chi ei defnyddio?

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* 4. Did you experience any difficulties with your video consultation today? Gwelwch chi unrhyw anawsterau gydag eich ymgynghoriad fideo heddiw?

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* 5. How did your video consultation benefit you today? Sut aeth yr ymgynghoriad fideo buddio chi heddiw?

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* 6. How many times have you used video for a health or social care consultation, and would you use it again? Sawl gwaith ydych chi wedi defnyddio fideo am ymgynghoriad iechyd neu ofal iechyd, a byddwch chi’n defnyddio eto?

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* 7. What was your video consultation related to today? Beth oedd eich ymgynghoriad fideo yn ynghylch heddiw?

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* 8. Do you feel that this video consultation prevented you needing a face-to-face appointment? (In other words, did you NOT need to attend in-person after this video for this appointment needs only) Wnaeth yr ymgynghoriad fideo osgoi’r angen i’r claf gael apwyntiad wyneb i wyneb?

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* 9. For your video consultation today, what type of healthcare speciality and professional did you see? Am eich ymgynghoriad fideo heddiw, pa fath o arbenigwr a phroffesiwn gwelwch chi?

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* 10. Whose choice was it to have a video consultation today? Dewis pwy oedd cael ymgynghoriad fideo heddiw?

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* 11. How long would it typically take you to travel from your home to your consultation? (one way) Pa mor hir fyddai hi'n cymryd i chi deithio i'ch apwyntiad fel arfer?

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* 12. Which Health Board Region are you in? O ba Ranbarth Bwrdd Iechyd ydych chi’n dod?

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* 13. What is your local area/authority? Beth yw eich ardal / awdurdod lleol?

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* 14. How would the patient describe themselves? Sut yw’r claf yn disgrifio ei hun?

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* 15. As a result of your Video Consultation today, do you (or the patient) feel you are: Fel ganlyniad i'ch ymweliad heddiw, a ydych chi'n teimlo eich bod chin

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* 16. Any other comments, questions or concerns? Unrhyw sylwadau, cwesitynau neu bryderon eraill?For example: How could your experience of video consulting today been improved?What additional support would have helped?

* 8. Do you feel that this video consultation prevented you needing a face-to-face appointment?

(In other words, did you NOT need to attend in-person after this video for this appointment needs only)

Wnaeth yr ymgynghoriad fideo osgoi’r angen i’r claf gael apwyntiad wyneb i wyneb?

* 16. Any other comments, questions or concerns?
Unrhyw sylwadau, cwesitynau neu bryderon eraill?

For example:
How could your experience of video consulting today been improved?
What additional support would have helped?