Life Lion Customer Service Survey 1Life Lion Customer Service Survey 1

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1. Please enter date and approximate time of transport.

	MM		DD		YYYY		HH		MM	AM/PM
Date/Time	Please enter date and approximate time of transport. Date/Time Month	/	Day	/	Year		Hour	:	Minute	AM or PM

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2. Tell us a little bit about who you are, (Name, phone #, and e-mail are optional).

Tell us a little bit about who you are, (Name, phone #, and e-mail are optional). Name:
Unit/Department/Hospital:
City/Town:
State:
Email Address:
Phone Number:

3. Please pick your provider level/certification/licensure.

	Provider Level
Provider Level	Please pick your provider level/certification/licensure. Provider Level Provider Level

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4. Type of transport:

Type of transport: Scene

Interhospital

Gift of Life

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5. How would you rate the ease of requesting Life Lion?

	Very Poor	Poor	OK	Good	Very Good	N/A
Ease of requesting:	*How would you rate the ease of requesting Life Lion? Ease of requesting: Very Poor	Ease of requesting: Poor	Ease of requesting: OK	Ease of requesting: Good	Ease of requesting: Very Good	Ease of requesting: N/A

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6. Did we arrive when we predicted?

	Definitely Late	A Little Late	Yes	Early	Really Early
On time?	*Did we arrive when we predicted? On time? Definitely Late	On time? A Little Late	On time? Yes	On time? Early	On time? Really Early

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7. Was the appearance of our staff acceptable?

	Not so good	A Little Rough	Average, OK	Better Than Average	Picture Perfect
Appearance:	*Was the appearance of our staff acceptable? Appearance: Not so good	Appearance: A Little Rough	Appearance: Average, OK	Appearance: Better Than Average	Appearance: Picture Perfect

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8. Was the staff courteous?

	Really grumpy.	A Little Grumpy	Yes	Better Than Average	Exceptional
Courteous:	*Was the staff courteous? Courteous: Really grumpy.	Courteous: A Little Grumpy	Courteous: Yes	Courteous: Better Than Average	Courteous: Exceptional

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9. Was our staff knowledgable?

	Need a lot of updating.	Need a little updating.	Yes.	Smarter than the avarage bear.	Exceptional.
Knowledge:	*Was our staff knowledgable? Knowledge: Need a lot of updating.	Knowledge: Need a little updating.	Knowledge: Yes.	Knowledge: Smarter than the avarage bear.	Knowledge: Exceptional.

10. Likelihood of recommending us to others.

	Absolutely not.	Maybe not.	Yes.	More than likely.	Absolutely.
Recommendation?	*Likelihood of recommending us to others. Recommendation? Absolutely not.	Recommendation? Maybe not.	Recommendation? Yes.	Recommendation? More than likely.	Recommendation? Absolutely.

Other comments:

Life Lion Customer Service Survey 1
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