Name

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First Name

Last Name

What was the primary reason for transferring care from the birth center to the hospital?

Medical complications for the birthing person in labor

Medical complications for the birthing person after the baby was born

Medical complications for the baby

Concerns about labor progress

Pain management needs

Other

How satisfied were you with the communication and coordination between the birth center and the hospital during the transfer?

Very Dissatisfied

Dissatisfied

Neutral

Satisfied

Very Satisfied

Did you feel adequately informed about the transfer process and what to expect at the hospital?

No

Somewhat

Yes

Did you feel there was shared decision making between the provider and yourself regarding the decision to transfer?

No

Somewhat

Yes

How would you rate the support and care provided by the birth center staff during the transfer?

Very Poor

Poor

Neutral

Good

Excellent

Were you accompanied to the hospital by a Birth Center staff member?

Yes

No

While for many transferring care to the hospital is not ideal, overall how did the transfer experience impact your overall satisfaction with your birth experience?

Very Negative Impact

Negative Impact

Neutral

Good Impact

Great Impact

Which hospital did you transfer to?

OSF St. Joseph's Medical Center

Carle BroMenn Medical Center

How would you rate the care provided by the hospital staff after your transfer?

Very Poor

Poor

Neutral

Good

Excellent

Did the hospital staff communicate effectively with you regarding your care plan and any necessary procedures?

No

Somewhat

Yes

Were you satisfied with the pain management options available to you at the hospital?

Very Dissatisfied

Dissatisfied

Neutral

Satisfied

Very Satisfied

I did not use any pain management

How would you rate the environment of the hospital in terms of comfort and support during your stay?

Very Poor

Poor

Neutral

Good

Excellent