Memorial MedFlight Survey 2021 +
MedFlight Survey
Name: *
What Size T-Shirt do you wear? *
Address To Send T-Shirt(street/city/state/zip): *
Flight Number:
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
Receiving Facility
Which of the following best describes your title?
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
Very Good
Clear selection
Overall were you satisfied with the initial call to Memorial MedFlight and/or subsequent dispatch?
Very Poor
Very Good
Clear selection
For Scene Transports Only
Radio communications effective for landing zone operations
Very poor
Very good
Clear selection
Efficiency of the transfer once the team arrived
Very Poor
Very Good
Clear selection
The team worked well with others caring for the patient
Very Poor
Very Good
Clear selection
Post flight contact received from the air medical crew
Overall Assessment
Ease of working with our organization
Very Poor
Very Good
Clear selection
Likelihood of recommending our service to others
Very Poor
Very Good
Clear selection
Overall how satisfied were you with your experience
Not Satisfied
Very Satisfied
Clear selection
Comments:
Email Address
Telephone
Prefered method of contact
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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