Outreach Trip Report Form

Anonymous Feedback

Your feedback is important to us. Please share your experience honestly so we can continue improving our organization and the services we provide.

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This form is anonymous. You are not required to provide your name, email address, phone number, or any other contact information. Please share only the information you feel comfortable providing.

Contact Information

First Last

Phone

Country Phone Number

Trip Role

Audiologist

Student

Translator

Volunteer

Other

Outreach Trip

Type of Report (check all that apply)

Injury/Medical Issue

Behavior/Interpersonal Conflict

Facility/Equipment Problem

Transportation/Housing Issue

Ethical/Legal Concern

General Feedback/Suggestion

Other

Brief Description (What Happened? When? Who Was Involved?)

Do you want a response?

Yes

Preferred Contact Method?

Phone

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Entheos Audiology Cooperative – the 100% member-owned cooperative focused on the best practices for best patient outcomes with a give-as-you-go model that benefits patients, communities, and the future of hearing health care.

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