Please choose if you are:
* must provide value
A provider
A patient (or answering on behalf of a patient)
A provider
A patient (or answering on behalf of a patient)
Midwife (Certified Nurse, Licensed Direct Entry, Unlicensed Direct Entry, Unlicensed)
Doula (Certified, Trained, Volunteer, Family/Friend)
Maternal Provider (MD, DO, NP, RN)
Neonatal Provider (MD, DO, NP, RN)
EMS
Other
Midwife (Certified Nurse, Licensed Direct Entry, Unlicensed Direct Entry, Unlicensed)
Doula (Certified, Trained, Volunteer, Family/Friend)
Maternal Provider (MD, DO, NP, RN)
Neonatal Provider (MD, DO, NP, RN)
EMS
Other
Please select all that apply
What type of transfer was this?
* must provide value
Maternal
Neonatal
Both
Type of maternal transfer:
* must provide value
Intrapartum
Postpartum
Other
Unknown
Intrapartum
Postpartum
Other
Unknown
What was your role in the transfer?
* must provide value
I initiated the transfer
I received the transfer
Other
I initiated the transfer
I received the transfer
Other
From where did the transfer initiate?
* must provide value
Home birth Arrivals Birth Service BetterBirth - Layton BetterBirth - Orem The Birth Center - Murray Birth Journey Wasatch Midwifery I don't know Other
At which hospital was the transfer received?
* must provide value
Alta View Hospital - Sandy American Fork Hospital - American Fork Ashley Regional Medical Center - Vernal Bear River Valley Hospital - Tremonton Beaver Valley Hospital - Beaver Blue Mountain Hospital - Blanding Brigham City Community Hospital - Brigham City Cache Valley Hospital - North Logan Castleview Hospital - Price Cedar City Hospital - Cedar City Central Valley Medical Center - Nephi Davis Hospital and Medical Center - Layton Delta Community Hospital - Delta Fillmore Community Hospital - Fillmore Garfield Memorial Hospital - Panguitch Gunnison Valley Hospital - Gunnison Heber Valley Hospital - Heber Intermountain Layton Hospital Intermountain Medical Center - Murray Intermountain Medical Center - Spanish Fork Intermountain St. George Regional Hospital - St. George Jordan Valley Medical Center - West Jordan Kane County Hospital - Kanab Lakeview Hospital - Bountiful LDS Hospital - Salt Lake City Logan Regional Hospital - Logan Lone Peak Hospital - Draper McKay Dee Hospital - Ogden Moab Regional Hospital - Moab Mountain Point Medical Center - Lehi Mountain View Hospital - Payson Mountain West Medical Center - Tooele Ogden Regional Medical Center - Ogden Orem Community Hospital - Orem Park City Hospital - Park City Primary Children's Hospital - Salt Lake City Riverton Hospital - Riverton Salt Lake Regional Medical Center - Salt Lake City San Juan Hospital - Monticello Sanpete Valley Hospital - Mount Pleasant Sevier Valley Hospital - Richfield St. Marks Hospital - Salt Lake City Timpanogos Regional Hospital - Orem Uintah Basin Medical Center - Roosevelt University of Utah Hospital - Salt Lake City Utah Valley Hospital - Provo I don't know Other
Did hospital personnel accommodate your presence during assessments/procedures (if the woman wanted)?
* must provide value
Yes
No
Unsure
N/A
When your patient/client arrived at the hospital, did you communicate directly with the receiving team to provide clinical information?
* must provide value
Yes
No
N/A
Did you (the transferring provider) coordinate follow-up care for the mother/newborn with the receiving provider?
* must provide value
Yes
No
N/A
What was the reason follow-up care was not coordinated with the receiving provider?
Upon arrival at the hospital, where was the patient/client admitted?
* must provide value
Taken to the Emergency Department (for evaluation and triage)
Directly admitted to Labor and Delivery
Directly admitted to the Newborn Intensive Care Unit
Directly admitted to the floor (low acuity unit)
I don't know
N/A
Taken to the Emergency Department (for evaluation and triage)
Directly admitted to Labor and Delivery
Directly admitted to the Newborn Intensive Care Unit
Directly admitted to the floor (low acuity unit)
I don't know
N/A
Did you communicate directly with the transferring provider to obtain clinical information?
* must provide value
Yes
No
N/A
Did you (the receiving provider) coordinate follow-up care for the mother/newborn with the transferring provider?
* must provide value
Yes
No
N/A
What was the reason follow-up care was not coordinated with the transferring provider?
Was the UWNQC Transfer to Hospital Provider-to-Provider Form used in this Transfer?
* must provide value
Yes
No
I don't know
The Transfer to Hospital Provider-to-Provider Form facilitated communication between out-of and in-hospital providers.
Strongly Agree
Agree
Undecided
Disagree
Strongly Disagree
Strongly Agree
Agree
Undecided
Disagree
Strongly Disagree
Why was the form not used?
* must provide value
Did not know form existed
Did not want to use
Did not have access to the form
Forgot to use
Could not due to emergent situation
N/A
Other
Did not know form existed
Did not want to use
Did not have access to the form
Forgot to use
Could not due to emergent situation
N/A
Other
Additional Comments Regarding the Transfer Form:
Additional Comments Regarding the Transfer Process:
What type of transfer was this?
* must provide value
Maternal (for you)
Neonatal (for your baby)
Both
Maternal (for you)
Neonatal (for your baby)
Both
What type of maternal (for you) transfer was this?
* must provide value
Antepartum (before labor started, while I was still pregnant)
Intrapartum (while I was in labor)
Postpartum (after the baby was born)
I don't know
Antepartum (before labor started, while I was still pregnant)
Intrapartum (while I was in labor)
Postpartum (after the baby was born)
I don't know
Where were you and/or your baby transferred from?
* must provide value
Home birth
Arrivals Birth Service
BetterBirth - Layton
BetterBirth - Orem
The Birth Center - Murray
Birth Journey
Wasatch Midwifery
I don't know
Other
Home birth
Arrivals Birth Service
BetterBirth - Layton
BetterBirth - Orem
The Birth Center - Murray
Birth Journey
Wasatch Midwifery
I don't know
Other
Which hospital were you and/or your baby transferred to?
* must provide value
Alta View Hospital - Sandy American Fork Hospital - American Fork Ashley Regional Medical Center - Vernal Bear River Valley Hospital - Tremonton Beaver Valley Hospital - Beaver Blue Mountain Hospital - Blanding Brigham City Community Hospital - Brigham City Cache Valley Hospital - North Logan Castleview Hospital - Price Cedar City Hospital - Cedar City Central Valley Medical Center - Nephi Davis Hospital and Medical Center - Layton Delta Community Hospital - Delta Fillmore Community Hospital - Fillmore Garfield Memorial Hospital - Panguitch Gunnison Valley Hospital - Gunnison Heber Valley Hospital - Heber Intermountain Layton Hospital Intermountain Medical Center - Murray Intermountain Medical Center - Spanish Fork Intermountain St. George Regional Hospital--St. George Jordan Valley Medical Center - West Jordan Kane County Hospital - Kanab Lakeview Hospital - Bountiful LDS Hospital - Salt Lake City Logan Regional Hospital - Logan Lone Peak Hospital - Draper McKay Dee Hospital - Ogden Moab Regional Hospital - Moab Mountain Point Medical Center - Lehi Mountain View Hospital - Payson Mountain West Medical Center - Tooele Ogden Regional Medical Center - Ogden Orem Community Hospital - Orem Park City Hospital - Park City Primary Children's Hospital - Salt Lake City Riverton Hospital - Riverton Salt Lake Regional Medical Center - Salt Lake City San Juan Hospital - Monticello Sanpete Valley Hospital - Mount Pleasant Sevier Valley Hospital - Richfield St. Marks Hospital - Salt Lake City Timpanogos Regional Hospital - Orem Uintah Basin Medical Center - Roosevelt University of Utah Hospital - Salt Lake City Utah Valley Hospital - Provo I don't know Other
What was the speciality of your out-of-hospital provider?
* must provide value
Midwife (Certified Nurse, Licensed Direct Entry, Unlicensed Direct Entry, Unlicensed)
Doula (Certified, Trained, Volunteer, Family/Friend)
Maternal Provider (MD, DO, NP, RN)
Neonatal Provider (MD, DO, NP, RN)
EMS
Other
Midwife (Certified Nurse, Licensed Direct Entry, Unlicensed Direct Entry, Unlicensed)
Doula (Certified, Trained, Volunteer, Family/Friend)
Maternal Provider (MD, DO, NP, RN)
Neonatal Provider (MD, DO, NP, RN)
EMS
Other