COPY: Ethicon- MAP International Medical Mission Feedback Form

Medical Mission Feedback

Please take approximately 10 minutes to fill out this this form and tell us about your Medical Mission.
Name*

First NameLast Name
Account Name or Number
Your account name or number can be found in your tracking email.
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Trip Departure Date*

MonthDayYear
Please provide the actual trip departure date.
Where was the primary location of your mission trip?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
If available, please provide the approximate number of people served on this mission:
Did you have any MAP donated products left at the end of your mission?*

YesNo
If yes, tell us what you did with the MAP donated products.
Were any changes made to the destination country in your original request?*

YesNo
If yes, tell us what changes were made.
Fistula Feedback - Data Analysis

ONLY fill this section out if you took Fistula products with you on your trip.
Please provide the total number of surgeons reached and list the name(s) of each.
Please provide the names of each hospital or clinic served.
Please provide the approximate number of patients served on this mission:
Please provide the number of surgeries performed while on this mission.
Please provide the Fistula Surgical Type.
If instruments were left in country, are they still being used in the associated clinics or hospitals?

YesNo
If Instruments were donated or left in country, please provide the clinic name(s) and the clinic contact(s) email address.
Patient Impact Story

Tell us a powerful story about a person you treated or helped on this medical mission trip using MAP-donated products.
Patient's Name
Please provide the patient's first name, if possible.
What MAP donated products were specifically used in this story?
Patient's Impact Story*
Please provide as much of the following information as possible, such as: the hospital or clinic where you served, health condition(s) treated, patient background and need, or any details that specifically impacted this patient before or after treatment. Do you know any background information about the patient? (Financial situation, family, able to work, hobbies they have had to stop because of their condition/illness that they are looking forward to resuming, etc. Please include any details that can describe this person more fully than just their illness.)
Impact Story Photos / Videos

Please upload 1-5 patient impact story photos and/or videos.
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Upload Your Best Footage

Please upload your best trip photos and/or videos additional to your impact story photos and/or videos.
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Thank you for completing the Medical Mission Feedback Form. Your information and input will be very helpful as we continue to provide services to compassionate healthcare providers like you.
By signing below and submitting this feedback information I grant permission to MAP International and its corporate partners to use photographs, stories and other information provided as customer feedback for the promotion of MAP International's and its corporate partners' mission and work around the globe. These photos will remain the property of MAP International and will not be sold for profit. I understand that I have voluntarily allowed photographs to be taken and have voluntarily submitted them to MAP International and that I will receive no payment for the photographs or for allowing the photographs to be taken. MAP may contact you if further information is needed and reserves the right to review your eligibility to receive future shipments. If you need assistance please call 1.800.225.8550.
Signature*

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Medical Mission Feedback

Fistula Feedback - Data Analysis

Patient Impact Story

Thank you for completing the Medical Mission Feedback Form. Your information and input will be very helpful as we continue to provide services to compassionate healthcare providers like you.