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Memorial MedFlight Survey 2023
MedFlight Survey
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* Indicates required question
Name:
*
Your answer
What Size T-Shirt do you wear(optional)?
Choose
S
M
L
XL
XXL
XXXL
Address To Send T-Shirt. Please include your City, State and Zip Code:
Your answer
Flight Number:
Your answer
Our promise is to provide the best medical care possible. We thank you in advance for completing the following questions so that we can continue to improve the quality of our services.
Date of Transport
MM
/
DD
/
YYYY
Referring Facility /Agency
*
Your answer
Receiving Facility
Your answer
Which of the following best describes your title?
*
Choose
Physician
Nurse
Paramedic
Hospital Rep
Police Officer
EMS Officer
Fire Officer
Dispatcher
Arranging Transport
Instructions: Please rate your satisfaction with the following aspects of our air medical transport services. 1= Very Poor, 5= Very Good
Professionalism of the person you called for transport
Very Poor
1
2
3
4
5
Very Good
Clear selection
Overall were you satisfied with the initial call to Memorial MedFlight and/or subsequent dispatch?
Very Poor
1
2
3
4
5
Very Good
Clear selection
For Scene Transports Only
Radio communications effective for landing zone operations
Very poor
1
2
3
4
5
Very good
Clear selection
Efficiency of the transfer once the team arrived
Very Poor
1
2
3
4
5
Very Good
Clear selection
The team worked well with others caring for the patient
Very Poor
1
2
3
4
5
Very Good
Clear selection
Post flight contact received from the air medical crew
Yes
No
Overall Assessment
Ease of working with our organization
Very Poor
1
2
3
4
5
Very Good
Clear selection
Likelihood of recommending our service to others
*
Very Poor
1
2
3
4
5
Very Good
Overall how satisfied were you with your experience
Not Satisfied
1
2
3
4
5
Very Satisfied
Clear selection
Comments:
Your answer
Email Address
Your answer
Telephone
Your answer
Preferred method of contact
Email
Phone
Clear selection
Thank you for the opportunity to be of service !!
If you have any difficulty with this form, contact Mark Berger; Office: 574-780-1260 or
mberger@beaconhealthsystem.org
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