EMS Patient Survey

The Forest Park Fire Department

Question Title

* 1. Your relation to the patient:

Self

Parent

Other family

Friend

Other

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* 2. Patient's age:

0 - 16

17 - 30

31 - 44

45 - 54

55 - 64

65 - Older

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* 3. Did you experience or witness the care given by paramedics?

Yes

No

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* 4. If you experienced or witnessed the care given by paramedics, please evaluate the following:

	Excellent	Good	Fair	Poor	Not Sure
Paramedics' concern for you/patient	Paramedics' concern for you/patient Excellent	Paramedics' concern for you/patient Good	Paramedics' concern for you/patient Fair	Paramedics' concern for you/patient Poor	Paramedics' concern for you/patient Not Sure
Paramedics' ability to listen to you/patient	Paramedics' ability to listen to you/patient Excellent	Paramedics' ability to listen to you/patient Good	Paramedics' ability to listen to you/patient Fair	Paramedics' ability to listen to you/patient Poor	Paramedics' ability to listen to you/patient Not Sure
Paramedics' information about your/patient's care options	Paramedics' information about your/patient's care options Excellent	Paramedics' information about your/patient's care options Good	Paramedics' information about your/patient's care options Fair	Paramedics' information about your/patient's care options Poor	Paramedics' information about your/patient's care options Not Sure
Paramedics' concern for your/patent's privacy	Paramedics' concern for your/patent's privacy Excellent	Paramedics' concern for your/patent's privacy Good	Paramedics' concern for your/patent's privacy Fair	Paramedics' concern for your/patent's privacy Poor	Paramedics' concern for your/patent's privacy Not Sure
Degree to which the paramedics listened to you and/or your family	Degree to which the paramedics listened to you and/or your family Excellent	Degree to which the paramedics listened to you and/or your family Good	Degree to which the paramedics listened to you and/or your family Fair	Degree to which the paramedics listened to you and/or your family Poor	Degree to which the paramedics listened to you and/or your family Not Sure
Paremedics' professionalism	Paremedics' professionalism Excellent	Paremedics' professionalism Good	Paremedics' professionalism Fair	Paremedics' professionalism Poor	Paremedics' professionalism Not Sure