DukeLifeFlight
First Name
Last Name
Contact Number
* Email Address
Organization
Department
1 * What is your prefered method of contact for feedback?
Choose one
None Needed
Phone
Email
2 * Referring/Receiving Agency Type Filling out Survey
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EMS Agency
Hospital
Long Term Care Facility
Patient
Other
3 * Please select your job title.
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Administrator
Case Manager
Communicator
EMT/EMT-P
Firefighter
Nurse
Patient
Physician
RRT/RCP
Other
4
* Date of Transport.
5 * How was this patient transported?
Choose one
Helicopter
Ambulance
Fixed Wing
* Why did you choose Duke Life Flight for this transport?
*****Please answer the following questions using the scale listed below*****
1=Poor; 2=Fair; 3=Good; 4= Very Good; 5= Excellent
6 * How would you rate your interaction with the Life Flight Communication's staff?
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7 * How well did the Life Flight crew communicate with the patient and family?
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5
8 * How well did the Life Flight crew communicate with the staff?
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5
9 * How well did the Life Flight crew work together with the referring staff?
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5
10 * How would you rate Life Flight's quality of care given to the patient?
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11 * How do you rate your overall experience with Life Flight?
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12 * How would you rate the overall attitude of the Life Flight crew?
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13 * How likely are you to use Life Flight again for your critical care transport needs?
Choose one
Definitely Will
Probably Will
Not Sure
Probably Will Not
Definitely Will Not
Additional Comments and Suggestions:
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