1. What is your age?

2. In general, how would you rate your overall health?

3. How long has it been since your most recent visit with your healthcare provider?

4. Is your healthcare provider, the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

5. In the last 12 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?

6. In the past 12 months, have you called 911 for assistance 3 or more times for the same condition or problem?

7. In the last 12 months, how many times did you call the fire department for assistance?

8. How satisfied are you with the services provided by your fire department?

9. Which of the following services would you be interested in receiving from a community paramedic program? (Check all that apply)

10. How likely are you to utilize a community paramedic?