SurveyMonkey Powered Online Survey

1. Patient Billing Account Number or Name:

Patient Billing Account Number or Name:

2. Date of Service

	MM		DD		YYYY
MM/DD/YYYY	Date of Service MM/DD/YYYY Month	/	Day	/	Year

3. Dispatch 911

	Outstanding	Excellent	Average	Fair	Poor	N/A
Helpfulness of the person you called for ambulance service	Dispatch 911 Helpfulness of the person you called for ambulance service Outstanding	Helpfulness of the person you called for ambulance service Excellent	Helpfulness of the person you called for ambulance service Average	Helpfulness of the person you called for ambulance service Fair	Helpfulness of the person you called for ambulance service Poor	Helpfulness of the person you called for ambulance service N/A
Instructions given prior to arrival of the ambulance	Instructions given prior to arrival of the ambulance Outstanding	Instructions given prior to arrival of the ambulance Excellent	Instructions given prior to arrival of the ambulance Average	Instructions given prior to arrival of the ambulance Fair	Instructions given prior to arrival of the ambulance Poor	Instructions given prior to arrival of the ambulance N/A
Call handled in a prompt, courteous, and competent manner	Call handled in a prompt, courteous, and competent manner Outstanding	Call handled in a prompt, courteous, and competent manner Excellent	Call handled in a prompt, courteous, and competent manner Average	Call handled in a prompt, courteous, and competent manner Fair	Call handled in a prompt, courteous, and competent manner Poor	Call handled in a prompt, courteous, and competent manner N/A

4. Ambulance

	Outstanding	Excellent	Average	Fair	Poor	N/A
Timeliness of response to your location	Ambulance Timeliness of response to your location Outstanding	Timeliness of response to your location Excellent	Timeliness of response to your location Average	Timeliness of response to your location Fair	Timeliness of response to your location Poor	Timeliness of response to your location N/A
Cleanliness of the ambulance and equipment	Cleanliness of the ambulance and equipment Outstanding	Cleanliness of the ambulance and equipment Excellent	Cleanliness of the ambulance and equipment Average	Cleanliness of the ambulance and equipment Fair	Cleanliness of the ambulance and equipment Poor	Cleanliness of the ambulance and equipment N/A
Comfort of the ride	Comfort of the ride Outstanding	Comfort of the ride Excellent	Comfort of the ride Average	Comfort of the ride Fair	Comfort of the ride Poor	Comfort of the ride N/A

5. Ambulance Crew

	Outstanding	Excellent	Average	Fair	Poor	N/A
Professionalism of the crew	Ambulance Crew Professionalism of the crew Outstanding	Professionalism of the crew Excellent	Professionalism of the crew Average	Professionalism of the crew Fair	Professionalism of the crew Poor	Professionalism of the crew N/A
Information about your treatment	Information about your treatment Outstanding	Information about your treatment Excellent	Information about your treatment Average	Information about your treatment Fair	Information about your treatment Poor	Information about your treatment N/A
Care for you as a person	Care for you as a person Outstanding	Care for you as a person Excellent	Care for you as a person Average	Care for you as a person Fair	Care for you as a person Poor	Care for you as a person N/A
Request for patient information and delivery of privacy notice	Request for patient information and delivery of privacy notice Outstanding	Request for patient information and delivery of privacy notice Excellent	Request for patient information and delivery of privacy notice Average	Request for patient information and delivery of privacy notice Fair	Request for patient information and delivery of privacy notice Poor	Request for patient information and delivery of privacy notice N/A
Overall care received from the crew	Overall care received from the crew Outstanding	Overall care received from the crew Excellent	Overall care received from the crew Average	Overall care received from the crew Fair	Overall care received from the crew Poor	Overall care received from the crew N/A

6. Office Staff

	Outstanding	Excellent	Average	Fair	Poor	N/A
Professionalism of office staff	Office Staff Professionalism of office staff Outstanding	Professionalism of office staff Excellent	Professionalism of office staff Average	Professionalism of office staff Fair	Professionalism of office staff Poor	Professionalism of office staff N/A
Willingness of staff to address your needs	Willingness of staff to address your needs Outstanding	Willingness of staff to address your needs Excellent	Willingness of staff to address your needs Average	Willingness of staff to address your needs Fair	Willingness of staff to address your needs Poor	Willingness of staff to address your needs N/A
If you interacted with our billing company, rate your overall experience	If you interacted with our billing company, rate your overall experience Outstanding	If you interacted with our billing company, rate your overall experience Excellent	If you interacted with our billing company, rate your overall experience Average	If you interacted with our billing company, rate your overall experience Fair	If you interacted with our billing company, rate your overall experience Poor	If you interacted with our billing company, rate your overall experience N/A

7. Overall Assessment

	Outstanding	Excellent	Average	Fair	Poor	N/A
Our staff worked together to care for you	Overall Assessment Our staff worked together to care for you Outstanding	Our staff worked together to care for you Excellent	Our staff worked together to care for you Average	Our staff worked together to care for you Fair	Our staff worked together to care for you Poor	Our staff worked together to care for you N/A
Overall rating of the care provided by us	Overall rating of the care provided by us Outstanding	Overall rating of the care provided by us Excellent	Overall rating of the care provided by us Average	Overall rating of the care provided by us Fair	Overall rating of the care provided by us Poor	Overall rating of the care provided by us N/A

8. Additional comments for any questions that you rated outstanding or poor:

Additional comments for any questions that you rated outstanding or poor:

9. If a member of our team was especially helpful, let us know who they are. We would like to share this information with them.

If a member of our team was especially helpful, let us know who they are. We would like to share this information with them.

10. How many times have you used the ambulance service in the last 12 months?

How many times have you used the ambulance service in the last 12 months?

11. Age group of patient

Age group of patient 0-18

19-45

46-64

65-older

12. Contact Information (Optional)

Contact Information (Optional) Email Address:
Phone Number:

Manatee County Emergency Medical Services Patient Survey