CHETA Evaluation Form

CHETA - Children's Hospital Emergency Transport Ambulance

Our goal is to provide you with the best transport service possible. We recognize the unique needs of pediatric patients and have developed CHETA in response to your needs. Please help us continue to improve our service by completing the following survey.

Please rate the following:

Communications

	Excellent	Good	Satisfactory	Unsatisfactory	N/A
Ease of initiating transport	*Please rate the following: Communications Ease of initiating transport Excellent	Ease of initiating transport Good	Ease of initiating transport Satisfactory	Ease of initiating transport Unsatisfactory	Ease of initiating transport N/A
Professionalism of dispatcher	Professionalism of dispatcher Excellent	Professionalism of dispatcher Good	Professionalism of dispatcher Satisfactory	Professionalism of dispatcher Unsatisfactory	Professionalism of dispatcher N/A
Courtesy of dispatcher	Courtesy of dispatcher Excellent	Courtesy of dispatcher Good	Courtesy of dispatcher Satisfactory	Courtesy of dispatcher Unsatisfactory	Courtesy of dispatcher N/A
Promptness	Promptness Excellent	Promptness Good	Promptness Satisfactory	Promptness Unsatisfactory	Promptness N/A
Accuracy of quoted arrival time	Accuracy of quoted arrival time Excellent	Accuracy of quoted arrival time Good	Accuracy of quoted arrival time Satisfactory	Accuracy of quoted arrival time Unsatisfactory	Accuracy of quoted arrival time N/A
Informative/supportive physician	Informative/supportive physician Excellent	Informative/supportive physician Good	Informative/supportive physician Satisfactory	Informative/supportive physician Unsatisfactory	Informative/supportive physician N/A

Please rate the following:

Transport Team

	Excellent	Good	Satisfactory	Unsatisfactory	N/A
Professionalism (Courteous)	*Please rate the following: Transport Team Professionalism (Courteous) Excellent	Professionalism (Courteous) Good	Professionalism (Courteous) Satisfactory	Professionalism (Courteous) Unsatisfactory	Professionalism (Courteous) N/A
Efficiency (Timely)	Efficiency (Timely) Excellent	Efficiency (Timely) Good	Efficiency (Timely) Satisfactory	Efficiency (Timely) Unsatisfactory	Efficiency (Timely) N/A
Proficiency (Clinically competent)	Proficiency (Clinically competent) Excellent	Proficiency (Clinically competent) Good	Proficiency (Clinically competent) Satisfactory	Proficiency (Clinically competent) Unsatisfactory	Proficiency (Clinically competent) N/A
Interactions with patient's family	Interactions with patient's family Excellent	Interactions with patient's family Good	Interactions with patient's family Satisfactory	Interactions with patient's family Unsatisfactory	Interactions with patient's family N/A

Please rate the following:

Follow-up

	Excellent	Good	Satisfactory	Unsatisfactory	N/A
Timely follow-up provided within 24 hours	*Please rate the following: Follow-up Timely follow-up provided within 24 hours Excellent	Timely follow-up provided within 24 hours Good	Timely follow-up provided within 24 hours Satisfactory	Timely follow-up provided within 24 hours Unsatisfactory	Timely follow-up provided within 24 hours N/A
Educational (if requested)	Educational (if requested) Excellent	Educational (if requested) Good	Educational (if requested) Satisfactory	Educational (if requested) Unsatisfactory	Educational (if requested) N/A
Overall experience with CHETA	Overall experience with CHETA Excellent	Overall experience with CHETA Good	Overall experience with CHETA Satisfactory	Overall experience with CHETA Unsatisfactory	Overall experience with CHETA N/A

Please feel free to share any comments or feedback below:

Please complete the following:

Please complete the following: Your name:
MD/RN/Other:
Address:
Phone:
Fax:
Email:

Would you like to be contacted by the CHETA Coordinator or Medical Director?

Would you like to be contacted by the CHETA Coordinator or Medical Director? Yes

If you have any immediate concerns and would like to contact a CHETA Coordinator, please contact us at: smcvicar@uwhealth.org.

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