Information Request Form

  Health Professions Tracking Service



Customer Satisfaction        Official logo medium

We work hard to assure accurate information & welcome the opportunity to improve customer satisfaction...

The HPTS Team takes pride in delivering  quality information in a timely manner and we value your opinion. Please let us know how we can deepen relationships and build on our success to better serve you by completing the brief survey below.

1. Which of the following product(s) have you used?


Electronic File


 Mailing Labels


 Statistical Summary



2. The product(s) met my expectations.

Strongly Agree




Strongly Disagree


3. The timeliness of the product(s) delivery met my expectations.

Strongly Agree




Strongly Disagree


4. The quality of the HPTS customer service met my expectations.

Strongly Agree




Strongly Disagree


5. The HPTS collects and maintains information on the following.  Please check all that are of interest to you.


 Physician Assistants

 Nurse Practitioners



 Hospital Administrators/CEO's

 Laboratory Directors

 Microbiology Coordinators

 Infection Control Nurses

 Emergency Nurses

 Public Health Officials

 Water Operators


 Behavioral Health Professionals

 First Responders

 Respiratory Care Practitioners


 Clinics/Practice Locations 


 Dental Offices

 Long Term Care & Assisted Living Facilities

 Medical Suppliers and Services

 Emergency Medical Services

 Fire Services



6. The HPTS maintains information in Nebraska and Western Iowa.  Please check the geographic areas of interest to you.


 Western Iowa

 Nebraska and Western Iowa

 Additional States or Geographic Areas:


7. I plan to request services from the HPTS in the near future.

Strongly Agree




Strongly Disagree


cover 2006 very small 8. Would your organization be interested in advertising in the HPTS Directory of Nebraska & Western Iowa Healthcare Resources



 Undecided. Please contact me to provide additional information.  


9. Please provide additional comments regarding the HPTS products or customer service you received.



10. Please define additional products or services of interest to you.

Contact Information (Optional)


Business Name

Contact Name

Mailing Address 1

Mailing Address 2





Zip Code



Email Address


Thank you for taking time out of your busy schedule to help us improve to meet your business needs.





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Health Professions Tracking ServiceTM

984330 Nebraska Medical Center

Omaha, NE 68198-4330

Phone: (402) 559-2901  Fax: (402) 559-9695

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