Fillable Serccot Survey (Commonwealth of Massachusetts)

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Serccot Survey (Commonwealth of Massachusetts)

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Medical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs Assessment
SERCCandTheGreaterAttleboroRegionalTransitAuthority(GATRA)areconductingthissurveytoidentifygapsintheregion'stransportationsystem,
especiallyasitrelatestomedicaltransportation.Also,SERCCseekstoinitiateacoordinatedcommunitysystemofnonemergencymedicaltransportation
forseniors60yearsandolder,peoplewithdisabilities,andlowincomeindividuals.
Pleasebeassuredthatyouranswersareconfidential.
ThedeadlineforcompletingthissurveyisFriday,October31,2014.
Thankyouforyourhelp.SurveyresultswillbeavailableontheGATRAwebsiteat:http://www.gatra.org/index.php/contactus/rccmeetings/inaboutamonth.
1.Howwouldyoudescribeyourorganization?
2.Toyourknowledge,whatpercentageofpatientappointmentsaremissedorcancelled
eachmonthduetolackoftransportation?
3.Doesyourorganizationprovidetransportationdirectlytopatients?
MedicalCenter
Hospital
VAMedicalClinicorHospital
MunicipalHealthDepartment
Dialysis/KidneyCenter
MentalHealthFacility/OutPatientCounseling
RehabilitationServices
HospiceServices
Other(pleasespecify)
Lessthan10%
10%20%
20%30%
morethan30%
Notapplicable
Yes
No
Medical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs Assessment
4.Pleaseindicatethetypeoftransportationprovided.
5.Whataretheoperatingdaysandhoursforyourtransportationservices?
6.Haveyoucoordinatedwithotherorganizations,communitybasedgroups,ortransit
authoritiestoprovidetransportationtopatients?
7.Pleaselistallorganizationsthatyouhavecoordinatedwithbelow.
8.Whataretheoperatingdaysandhoursforthesetransportationservices?
9.Doesyourorganizationprovidetransportationthroughacontractedbroker/provider?
10.Pleaseincludedetailsaboutthetransportationyoucontractoutbelow.
Sharedambulatoryvan
Sharedaccessiblevan
Stretchervan
Ambulance
Other(pleasespecify)
Yes
No
Yes
No
Medical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs Assessment
11.Pleaseindicatethetypeofcontractedtransportationprovided.
12.Whataretheoperatingdaysandhoursforthesecontractedtransportationservices?
13.Doyouhaveknowledgeoftheavailabletransportationservicesinyourarea?
14.Doesyourorganizationprovideinformationtopatientsaboutavailabletransportation
servicesinthearea?
15.Wouldyouliketoprovideinformationaboutavailabletransportationoptionstoyour
patients?
16.AreyoufamiliarwithGATRA'stransportationinventorywebsite,RideMatch,
(www.massridematch.org)?
PublicTransportation
Taxi/sedan
Sharedambulatoryvan
Sharedaccessiblevan
Stretchervan
Ambulance
Other(pleasespecify)
Yes
No
Yes
No
Yes
No
Yes
No
Medical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs Assessment
17.Haveyouusedthewww.massridematch.orgwebsitetolocatetransportationoptionsin
southeasternMassachusetts?
18.DoesyourorganizationprovidescreeningorADAeligibilityformsfortransportation
services?
19.Doesanyoneatyourorganizationmaketransportationarrangementsforpatients?
20.Pleaseprovidethename,phone,andemailofthepersonwhomakestransportation
arrangements.
Name
Phone
Email
21.Doyouknowofanyotherserviceswithinthecommunitythatprovidemedical
transportation(fromanindividual'shometoamedicalservice)?
22.Pleaselistalltheservicesthatprovidemedicaltransportationinyourcommunity.
Yes
No
Yes
No
Yes
No
Yes
No
Medical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs AssessmentMedical Transportation Needs Assessment
23.WouldyouliketoparticipateinaForumonMedicalTransportationCoordinationtolearn
moreabouttransportationoptionsinthecommunityandtoassesscurrenttransportation
needs?
24.Pleaseprovideyourname,organization,phone,andemailsowemaycontactyouabout
attendingtheforum.
Name
Organization
Phone
Email
Yes
No
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Serccot Survey (Commonwealth of Massachusetts)

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Completed 26 July 2020

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