Smooth Transitions - Transfer Evaluation - Community-based Midwife

Program Description and Confidentiality Statement

You have reached the old version of the Smooth Transitions surveys. Please do not fill this out. Our new surveys can be found on the Smooth Transitions website at https://www.qualityhealth.org/smoothtransitions/surveys-2/

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* 1. Date of transfer

Date

Date

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* 2. Receiving Facility and County

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* 3. Type of Transfer

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* 4. What was/were the indication(s) for transfer?

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* 5. Urgency of transfer

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* 6. Mode of transfer