Medevac Alaska Feedback Form
Please complete this brief form of how we did. While not required we request you leave name and phone number so we may follow up with you when needed. In the feedback and comments section please leave specifics of any concerns or other information you would like us to know.
Email address *
Date of transport or issue: *
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DD
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Patient's Name or Initials (optional):
Your answer
Your name:
Name and title of person completing form (i.e. John Doe, or Jane Doe RN). Optional but requested.
Your answer
Contact phone (Optional):
Your answer
Role of individual completing survey: *
Type of Service *
Names of crew members (if available):
Your answer
On Time?
Did the Medevac Alaska Transport Team arrive at the bed side at or before the expected time?
Necessary Equipment?
Did the Medevac Alaska transport team arrive with all the necessary equipment to provide care during your transport?
Professionalism?
How professional was the crew from Medevac Alaska?
Overall Satisfaction?
Feedback/Concerns?
Do you have any specific concerns, Incident details, or feedback you would like to provide? Please include positive and/or negative experience as appropriate. You may also copy and paste longer text into this field.
Your answer
Would you like a supervisor to contact you regarding this survey?
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