MediCar Employee Quality Form
Please fill this form out in its entirety to the best of your ability.
Trainers Name:
*
First Name
Last Name
Trainees Name:
*
First Name
Last Name
Station Location:
*
Chicago
Elgin
Gurnee
Hammond
Hickory Hills
Naperville
Orland Park
Portage
Schiller Park
Shorewood
Understanding how to operate the hydraulic wheelchair lift:
*
1
2
3
4
5
1 = Not at all | 5 = Best
Understanding how to MANUALLY operate the lift:
*
1
2
3
4
5
1 = Not at all | 5 = Best
Demonstrated good customer service:
*
1
2
3
4
5
1 = Not at all | 5 = Best
Followed proper safety precautions:
*
1
2
3
4
5
1 = Not at all | 5 = Best
Making sure vehicle is equipped with all proper equipment (belts, tiedowns, etc.):
*
1
2
3
4
5
1 = Not at all | 5 = Best
Understand how to secure patients safely and properly in the vehicle:
*
1
2
3
4
5
1 = Not at all | 5 = Best
Uniform / Personal Appearance:
*
1
2
3
4
5
1 = Not at all | 5 = Best
Comments:
*
Date:
*
-
Month
-
Day
Year
Date
Trainers Signature:
*
Submit
Should be Empty: