This form is to be completed by the designated team leader within one week of returning from a volunteer trip to the South Pacific, and is necessary for DAISI to meet its mandatory reporting responsibilities.

    1. Are you the DAISI designated Team Leader responsible for reporting a recent volunteer trip to the South-Pacific?

    2. Your Name (required)

    3. Your Email (required)

    4. Your Mobile

    5. Trip Number

    6. Dates of Trip

    7. Nature of Trip (eg surgical, cardiac, paediatric, public health, fact finding, etc)

    8. Where did you spend most of your time volunteering?

    9. Which facility or hospital did you mostly volunteer at?

    10. Who is the responsible South-Pacific Partner also responsible for reporting for this trip?

    11. Was a DAISI briefing session conducted for volunteers prior to departing for volunteering in the South-Pacific?

    12. Were Objectives & Key Performance Indicators (KPIs) for the trip provided to you by DAISI prior to your volunteer trip?

    13. What were the top four KPI’s for your trip ?

    14. How well were each of these KPI’s met?

    KPI Number 1

    KPI Number 2

    KPI Number 3

    KPI Number 4

    15. How would you rate the preparation of patients by South-Pacific Partners in the facility/hospital you visited?

    16. How would you rate the volume of the workload or cases waiting for you during your visit?

    17. The primary objective of DAISI visits is to create lasting change through education, and a focus on teaching local doctors and nurses. How well was this objective achieved during this trip?

    18. Please explain how the primary objective of teaching was or wasn’t achieved, and influencing factors. (please type below)

    19. Please list the active South-Pacific Partners involved in this trip and their role (please type below)?

    20. Please explain the level of participation of host South-Pacific Partners listed above and factors that inhibited or enhanced their involvement. (please type below)

    21. The secondary objective of DAISI visits is to deliver health care services. How well was this objective achieved during this trip?

    22. Was lack of vital equipment an issue with this trip?

    23. What equipment needs to be obtained before another similar trip would be feasible? (please type below)?

    24. How many patients were screened during this trip? (please type below)?

    25. How many patients received treatment or surgery ? (please type below and email logbook to

    26. Were there any morbidity or mortality complications during your trip? (please type below)?

    27. How well was the objective of Service Delivery met this volunteer trip?

    28. Which Objectives & KPI’s were not met and why? (please type below)?

    29. Which changes need to be made for the next trip to facilitate achieving Objectives & KPI’s that were not met his trip? (please type below)?

    30. Was a debrief session conducted on site at the facility/hospital at the end of the trip?

    31. What was the quality of the debrief session

    32. Was the debrief session at the end of the trip attended adequately by South-Pacific Host Partners?

    33. How enthusiastic are your South-Pacific host Partners and hospital staff about you and/or a similar trip returning next year?

    34. Was there enough recreation time provided during the trip?

    35. Would you consider volunteering again with DAISI?

    36. Did you or any volunteer member become unwell or injured during your trip?

    37. Please explain if you or a volunteer member became unwell or injured during your trip? (please type below)?

    38. Was the trip a fun experience?

    39. Was the cost involved in making the trip prohibitive?

    40. How would you rate the overall experience?

    41. What needs to be improved? (please type below)?

    42. Do you have any further feedback (please type below)?

    43. Would you like a DAISI Executive member to call you to discuss your experience or any issues that arose?

    44. Do you agree to contact your South-Pacific Host Partner one month after your visit to obtain complete 30 day Morbidity & Mortality data to be sent to