Please fill in a valid value for all required fields
Please ensure all values are in a proper format.
Are you sure you want to leave this form and resume later?
Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.
Save and Resume Later
Save and get link
You must upload one of the following file types for the selected field:
There was an error displaying the form. Please copy and paste the embed code again.
Apply Discount
You saved
with code
Submit Form
Submitting
Validating
There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.
Please check the field:
Fields
Please choose one:
Intermountain Health Provider/Caregiver
Non-Intermountain Health Provider/Caregiver
Please indicate your department/role:
ED Provider
Urgent Care Provider
Hospitalist
Primary Care Clinic
Specialty Clinic
Hospital Caregiver/CM
Walk-In Clinic
Overall, how would you rate your experience using SCLHealth/IH One Call patient transfer center?
Excellent
Above Average
Average
Below Average
Poor
Please rank your interactions with SCLHealth/IH One Call in the following categories
Please rank your interactions with SCLHealth/IH One Call in the following categories
Excellent
Above Average
Average
Below Average
Poor
Efficiency during the referral intake process.
Please rank your interactions with SCLHealth/IH One Call in the following categories: Efficiency during the referral intake process. (Excellent)
Efficiency during the referral intake process. (Above Average)
Efficiency during the referral intake process. (Average)
Efficiency during the referral intake process. (Below Average)
Efficiency during the referral intake process. (Poor)
Timeliness of patient acceptance.
Timeliness of patient acceptance. (Excellent)
Timeliness of patient acceptance. (Above Average)
Timeliness of patient acceptance. (Average)
Timeliness of patient acceptance. (Below Average)
Timeliness of patient acceptance. (Poor)
Communication with transfer status updates.
Communication with transfer status updates. (Excellent)
Communication with transfer status updates. (Above Average)
Communication with transfer status updates. (Average)
Communication with transfer status updates. (Below Average)
Communication with transfer status updates. (Poor)
Courteousness and professionalism of call center caregiver.
Courteousness and professionalism of call center caregiver. (Excellent)
Courteousness and professionalism of call center caregiver. (Above Average)
Courteousness and professionalism of call center caregiver. (Average)
Courteousness and professionalism of call center caregiver. (Below Average)
Courteousness and professionalism of call center caregiver. (Poor)
If you are a referring provider, how satisfied are you with the overall process and the accepting/consulting physician experience?
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
N/A
If you are an accepting/consulting provider, how satisfied are you with the process of connecting with the referring provider and facility.
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
N/A
Please share your feedback about your overall experience with our transfer service.
Submission Date
https://intermountainhealth.formstack.com/forms/images/2/calendar.png
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Previous
←
Next
→
Enter your save and resume password
Cancel
Confirm