Hospital Feedback
Information you provide in this form will be forwarded to the Medical Services Captain of the Salt Lake City Fire Department and the EMS Liaison for your hospital
Your Name (Not Required)
First Name
Last Name
Hospital
Please Select
4th Street Clinic
Gail Miller Resource Center
Holy Cross Hospital - West Valley
Holy Cross Hospital - Salt Lake City
Intermountain Medical Center
LDS Hospital
Primary Children's Medical Center
St. Mark's Hospital
University of Utah Medical Center
VA Medical Center
West Valley ED - St. Mark's
Other
You selected "Other" please provide the Hospital name below:
Email address of your Hospital's EMS liaison
example@example.com
Date of Transfer
-
Month
-
Day
Year
Time of Transfer (24 Hour Format)
Salt Lake City Fire Department or Gold Cross Unit Number
Feedback Type
Please Select
BLS Transport of ALS Patient
Feedback for Hospital
Issue with Crew
Other Problem During Transport
Positive Feedback
Please tell us what happened and any other information that may be helpful. Thank you!
Please enter your email if you would like a copy of this form:
example@example.com
For your information - SLCFD ALS Transport Indicators
Click Here
to review
Submit
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