Date of Incident/Interaction
Date of Incident/Interaction
MM
DD
YYYY
Please enter the date and time you interacted with ski patrol. This will help us to identify the patroller(s) that you worked with. If you were given a business card, this information will be written on the back.
Approximate time of Incident/Interaction
Approximate time of Incident/Interaction
HH
MM
AM
PM
AM/PM
If you were treated by patrol and given a business card, this time will be written on the back of the card.
What was your interaction with ski patrol?
What was your interaction with ski patrol?
You were injured.
A family member was injured.
A friend was injured.
Other
Other
Did you or the injured person seek further medical care?
Did you or the injured person seek further medical care?
Yes
No
When did you/or the other person seek further medical care?
When did you/or the other person seek further medical care?
Immediately
The next day
Later
Other
Other
Where did you or the other person go for further medical care?
Where did you or the other person go for further medical care?
Divine Savior in Portage
St. Clare in Baraboo
Madison Area Hospital or clinic
Back to your home area
Other
Other
Where was your injury?
Where was your injury?
Upper Leg
Knee
Lower Leg
Ankle
Foot
Hip
Abdomen
Chest
Back
Neck
Shoulder
Arm
Wrist
Hand
Thumb
Head
Face
Eye
Nose
Mouth
Teeth
Other
You may check more than one area where you had an injury.
What was the diagnosis of the injury?
For example, did you have a fracture, a sprain, a dislocation, separation, concussion?
Did the treatment given by patrol change the pain level?
Yes--decreased it.
Yes--increased it.
No--did not change it.
Hard to tell.
Did you feel that the patroller(s) acted professionally?
Yes
No
Please explain, why you felt patrol was not professional and how we could have done better.
Did you feel that you/family/friend were treated with compassion?
Yes
No
Please explain, what made you feel you/family/friend were not treated with compassion, and what we could have done better.
Overall Rating *
Excellent
Good
Average
Below Average
Poor
Please give your interaction with ski patrol an overall rating.
Please add any additional comments that you may have.
Maximum of 10000 words allowed. Currently Entered: 0 words.
Do you wish to give us any contact information.
Yes
No
If you wish to give us your email or any contact information, you will be taken to the last page. If not, just click on Continue, and your feedback will be submitted.