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  1. Surveys
  2. 2012
  3. February
  4. M
  5. Mercy
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Date
 
 
 
Trip #
   
 
 
 
MID #
   
 
 
 
Were you satisfied with the transportation you received?
 
Yes
 
No
 
No trip taken
 
Don't remember
 
 
 
How soon did you arrive before your appointment?
 
15 minutes or less
 
16 to 60 minutes
 
More than an hour
 
 
 
How long did you wait for transportation to pick you up from the appointment?
 
15 minutes or less
 
16 to 60 minutes
 
More than an hour
 
One way
 
 
 
Where did you go?
 
PCP
 
ER
 
Pharmacy
 
Specialist
 
Other
 
 
 
Comments (Check all applicable)
 
No Comment
 
Happy
 
Rude Service
 
Late/Had to reschedule
 
Camcelled by member
 
Used alternate transportation
 
Poor Equipment
 
Problems with driver
 
Other

 
 
 
Comments/Suggestions:
   
 
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