|Age range classification||0–1 Y, > 1–10 Y, 11–20 Y, > 20 Y|
|Others (Neonatology, Transplantation)|
Origin of referral|
Classification of patients
Number of patients
Origin of referral for new patients (same hospital/other hospital)|
Total patients followed-up per year
Place of death (home, hospital, other)|
Total number of deaths
Duration of follow-up
Frequencies of admission in hospital
Mean average duration of admission
Number of contacts with families post-death
|Objectives and needs||
What objectives did you have? Which objectives did you achieve?|
Which objectives did you partially achieve? Why?
What are your needs? Which objective(s) did you not achieve? Why?
What are your objectives for next year?
Did your team change during this year?
|Strengths and weaknesses||
What are the strengths of your team?|
What are the weaknesses of your team?
What are the requests of the target group?|
What are the requests of the PLT?
What are the requests of services/institutions/hospitals?