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Raizer Chair Usage Log
This form is to be used by care providers who have received a Raizer Chair from FLEET. The details collected in the form will be used to monitor the impact of the chairs in reducing the demand on urgent and emergency services.
There is no need to provide any personal information about the person receiving care, you may optional provide your contact details if you would like to talk to somebody about the use of the chair.
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* Indicates required question
Date of Use
*
What date was the chair used on?
MM
/
DD
/
YYYY
What is your role
*
Name and location of nursing home or town care was provided
Nursing Home staff
Tri-service Responder
Other:
Where was the chair used
*
Name of nursing home and/or town
Your answer
How easy was it to use the chair?
*
Difficult
1
2
3
4
5
Easy
Did using the chair prevent an ambulance attending?
*
Yes
No
Required
Any other comments about using the raizer chair
Optionally, Feel free to provide any other feedback about the chair. If you would like to talk to someone about the chair, please leave your contact details here.
Your answer
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