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Feedback Form: Brigades/Medical Missions
Report Completed By:
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Recipient Organization
Sponsor Organization
Other
Name:
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First Name
Last Name
Organization
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Title
Phone Number
Email Address
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Verify Email
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Confidentiality Request: If any part of your feedback form or the enclosed materials cannot be shared publicly, please explain. (Information such as your personal contact information will never be sold/shared/publicly posted).
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Shipment Type
Hand-Carried/Small Shipment
Freight Shipment
20' Container Shipment
40' Container Shipment
Date Shipment Received from MedWish
(mm/dd/yyyy)
Date Supplies Arrived in Country
(mm/dd/yyyy)
Customer Satisfaction
Our ability to meet your wish list
Interaction with Our Employees
How likely are you to recommend Medwish to a colleague/peer organization
1 Unlikely
2
3
4
5 Very Likely
How likely are you to request supplies from Medwish in the future?
1 Unlikely
2
3
4
5 Very Likely
Any comments on customer satisfaction
Impact Report
Location of Brigade
Clinic/Hospital/Pop-Up Clinic Name
Number of Brigade Participants
Number of Brigade Work Stations
Type of Environment
Rural
City
Other
What services were offered?
Medical Care
Dental Care
Vision Care
Training
Public Health Education
Other
Number of patients seen?
Number of procedures performed?
MedWish Moments: These are stories and expereinces that continue with us after the brigade has completed.
Pictures To Share