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Feedback Form: Freight Shipment
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 Shipment 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
Any comments on customer satisfaction
Equipment and Supply Satisfaction
What percentage of supplies received were USEable?
Less than 50%
50-89%
90-100%
What supplies did you receive that were unusable, why?
How likely are you to request supplies from Medwish in the future?
1 Unlikely
2
3
4
5 Very Likely
Any Comments on the Equipment or Supplies?
Impact Report
Location Supplies Delivered to
Clinic/Hospital Name
Type of Environment
Rural
City
Other
What services/departments are offered?
Emergency Care
Pediatric Care
Maternity/OBGYN Care
Cardiac Care
Intensive Care
Other
Number of Patients seen daily
Number of Beds
What supplies received has the most impact?
MedWish Moments: These are stories and expereinces that continue with us after the brigade has completed.
Pictures To Share