Humanitarian Aid Feedback Form

This form is due back to MedWish 60 days after successful receipt of a humanitarian aid shipment. Please complete this form in full and submit it to info@medwish.org.

Click here to download a PDF of the feedback form.

You can also fax it to +1-216-274-6380 or mail it to

MedWish International
ATTN: Operations
1625 E. 31st Street
Cleveland, Ohio, USA 44114

Report Completed By*

Recipient OrganizationSponsor OrganizationOther

Name*

Organization*

Title*

Phone Number*

Email Address*

Relationship to Project*

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.)

Shipment Type*

Hand-carried/small shipmentFreight shipment20' container shipment40' container shipment

Date of shipment release from MedWish*

MonthDayYear

Date of arrival to recipient organization*

MonthDayYear

Customer Satisfaction

Please rate the following aspects of this particular shipment. If you were not involvedin a certain area, or if an item is not applicable to your shipment, please skip the question. Feel free to leave comments. Your feedback helps us improve!

Application process

Comments

Interaction with our employees

Comments

Technical support

Comments

Our ability to meet your wish list

Comments

Quality of items

Comments

Packing and loading (was anything broken, e.g.?)

Comments

Order fulfillment timeline

Comments

Value/fee for service

Comments

How likely are you to recommend MedWish to a colleague, peer organization?

	1	2	3	4	5

1 is Not at all likely, 5 is Very likely

Comments

How likely are you to request supplies from MedWish in the future?

	1	2	3	4	5

1 is Not at all likely, 5 is Very likely

Comments

Were there any items you were unable to receive from MedWish? If yes, were you able to get them donated elsewhere? Did you have to purchase them? Did you have to go without? Please explain.

0/500

Impact Report

1. Please briefly summarize the supplies and equipment received in your shipment and what programs or operations they support.*

0/500

2. Please describe the “before” and “after” of receiving this shipment. Include number of procedures performed, any new programs, increased patient numbers, etc. that occurred as a result of this shipment.*

0/500

3. Considering the issues presented in the application project narrative, how has your shipment helped address critical diseases and/or helped pursue short- and long-term goals of the organization?*

0/500

Suggested attachments

We appreciate your completion of this feedback form. You are welcome and encouraged to include supplemental materials to help us better understand how this shipment supported your work. Materials enclosed with this report cannot be returned; please send photocopies of documents or digital files of photos/videos.

(Please remember, unless you request otherwise, these items along with your feedback form may be shared publicly via our website, annual report, newsletter or other media.) You may also email your feedback to info@medwish.org.

Examples of items you could share:

Recorded or written interviews with patients, physicians or families. (Always get consent to share.)
Photos of patients who have benefited from the shipment along with a brief narrative including name, age, occupation/brief description and what health issues they face/how did MedWish supplies help.
Letters of thanks from patients or physicians.
Photos or video of your shipment being unpacked.
Your organization's newsletter, annual report or other materials.

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MedWish Humanitarian Aid Feedback Form