South Walton Fire District Patient Satisfaction Survey

	MM		DD		YYYY
Date you required a medical response from the South Walton Fire District.	Date of Service Date you required a medical response from the South Walton Fire District. Month	/	Day	/	Year

What is the patient's age? Under 18

18 to 30

31 to 44

45 to 54

55 to 64

65 or older

	Excellent	Good	Fair	Poor	N/A
Helpfulness of the 911 Dispatcher you called for ambulance services	*The person you called for service (911 Center Dispatcher) Helpfulness of the 911 Dispatcher you called for ambulance services Excellent	Helpfulness of the 911 Dispatcher you called for ambulance services Good	Helpfulness of the 911 Dispatcher you called for ambulance services Fair	Helpfulness of the 911 Dispatcher you called for ambulance services Poor	Helpfulness of the 911 Dispatcher you called for ambulance services N/A
Concern shown by the 911 Dispatcher	Concern shown by the 911 Dispatcher Excellent	Concern shown by the 911 Dispatcher Good	Concern shown by the 911 Dispatcher Fair	Concern shown by the 911 Dispatcher Poor	Concern shown by the 911 Dispatcher N/A
911 instructions were clear and concise until the paramedics arrived	911 instructions were clear and concise until the paramedics arrived Excellent	911 instructions were clear and concise until the paramedics arrived Good	911 instructions were clear and concise until the paramedics arrived Fair	911 instructions were clear and concise until the paramedics arrived Poor	911 instructions were clear and concise until the paramedics arrived N/A

Comments (describe positive or negative experiences)

	Excellent	Good	Fair	Poor	N/A
Ambulance response time	*The Ambulance Ambulance response time Excellent	Ambulance response time Good	Ambulance response time Fair	Ambulance response time Poor	Ambulance response time N/A
Cleanliness of the ambulance	Cleanliness of the ambulance Excellent	Cleanliness of the ambulance Good	Cleanliness of the ambulance Fair	Cleanliness of the ambulance Poor	Cleanliness of the ambulance N/A
Comfort of the ambulance ride	Comfort of the ambulance ride Excellent	Comfort of the ambulance ride Good	Comfort of the ambulance ride Fair	Comfort of the ambulance ride Poor	Comfort of the ambulance ride N/A

Comments (describe positive or negative experiences)

	Excellent	Good	Fair	Poor
Showed genuine concern for my situation	*Firefighter/Paramedic personnel Showed genuine concern for my situation Excellent	Showed genuine concern for my situation Good	Showed genuine concern for my situation Fair	Showed genuine concern for my situation Poor
Handled themselves professionally	Handled themselves professionally Excellent	Handled themselves professionally Good	Handled themselves professionally Fair	Handled themselves professionally Poor
Displayed professional and neat appearance	Displayed professional and neat appearance Excellent	Displayed professional and neat appearance Good	Displayed professional and neat appearance Fair	Displayed professional and neat appearance Poor
Treated me with respect, compassion, and care for my injury/illness	Treated me with respect, compassion, and care for my injury/illness Excellent	Treated me with respect, compassion, and care for my injury/illness Good	Treated me with respect, compassion, and care for my injury/illness Fair	Treated me with respect, compassion, and care for my injury/illness Poor
Offered quality, competent care throughout treatment	Offered quality, competent care throughout treatment Excellent	Offered quality, competent care throughout treatment Good	Offered quality, competent care throughout treatment Fair	Offered quality, competent care throughout treatment Poor

Comments (describe positive or negative experiences)

	Excellent	Good	Fair	Poor
How well did our staff work together to care for you	*Overall Assessment How well did our staff work together to care for you Excellent	How well did our staff work together to care for you Good	How well did our staff work together to care for you Fair	How well did our staff work together to care for you Poor
The provided services were worth the fees charged	The provided services were worth the fees charged Excellent	The provided services were worth the fees charged Good	The provided services were worth the fees charged Fair	The provided services were worth the fees charged Poor
Quality of care provided by the SWFD	Quality of care provided by the SWFD Excellent	Quality of care provided by the SWFD Good	Quality of care provided by the SWFD Fair	Quality of care provided by the SWFD Poor
How would you rate your overall experience with the South Walton Fire District	How would you rate your overall experience with the South Walton Fire District Excellent	How would you rate your overall experience with the South Walton Fire District Good	How would you rate your overall experience with the South Walton Fire District Fair	How would you rate your overall experience with the South Walton Fire District Poor

Comments (describe positive or negative experiences)

Any suggestions to enhance our service?

May we contact you regarding your comments or concerns No

Yes

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