Dell Children’s Medical Center of Central Texas
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Pediatric Critical Care Transport TeamPost Transfer Survey

Please assist us in improving our service by answering the following questions using the scale below.
Fields outlined in orange are required.

Transport number
(Please refer to transport number at bottom of follow up letter.)

Strongly Agree = 5   Agree = 4     Neutral =   3    Disagree = 2    Strongly Disagree = 1
Pre Transport 5 4 3 2 1
A.  Transport was easy to arrange
B.  Person triaging the call was polite, respectful and efficient
C.  I was given an accurate estimated time of arrival
Intra Transport 5 4 3 2 1
A.  Transport team treated referring staff respectfully
B.  Patient was treated appropriately and was packaged efficiently
Post Transport 5 4 3 2 1
A.  I received a post transport phone call from the team
B.  Overall, I am satisfied with this transfer
Submitted by:
Phone:
Email:
Comments: (If answered 1 or 2 on any items above, please elaborate)
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