Patient Satisfaction Survey

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* 1. Date of Call / Incident:

Enter the date that Good Fellowship's services were used.

Date

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* 2. Please tell us which services from Good Fellowship you received:

Ambulance from Good Fellowship

Good Fellowship Paramedic provided care in another agency's ambulance (Goshen Fire Co., East Whiteland Fire Co., Kennett Fire Co. etc)

I'm Not Sure

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* 3. Please tell us your relationship to the patient:

Self

Parent

Other Family

Friend

Other (please specify)

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* 4. Did you feel the ambulance's response time was:

Faster Than Expected

Adequate

Slower Than Expected

Too Slow

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* 5. Please evaluate the following regarding the EMS Providers:

	Excellent	Good	Neutral	Fair	Poor	N/A
Concern for the patient	Concern for the patient Excellent	Concern for the patient Good	Concern for the patient Neutral	Concern for the patient Fair	Concern for the patient Poor	Concern for the patient N/A
Ability to listen to the patient	Ability to listen to the patient Excellent	Ability to listen to the patient Good	Ability to listen to the patient Neutral	Ability to listen to the patient Fair	Ability to listen to the patient Poor	Ability to listen to the patient N/A
Explaining care and treatment(s) so you understand	Explaining care and treatment(s) so you understand Excellent	Explaining care and treatment(s) so you understand Good	Explaining care and treatment(s) so you understand Neutral	Explaining care and treatment(s) so you understand Fair	Explaining care and treatment(s) so you understand Poor	Explaining care and treatment(s) so you understand N/A
Concern for patent's privacy	Concern for patent's privacy Excellent	Concern for patent's privacy Good	Concern for patent's privacy Neutral	Concern for patent's privacy Fair	Concern for patent's privacy Poor	Concern for patent's privacy N/A
Appearance	Appearance Excellent	Appearance Good	Appearance Neutral	Appearance Fair	Appearance Poor	Appearance N/A
Overall professionalism	Overall professionalism Excellent	Overall professionalism Good	Overall professionalism Neutral	Overall professionalism Fair	Overall professionalism Poor	Overall professionalism N/A
Trust and confidence in skills	Trust and confidence in skills Excellent	Trust and confidence in skills Good	Trust and confidence in skills Neutral	Trust and confidence in skills Fair	Trust and confidence in skills Poor	Trust and confidence in skills N/A

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* 6. Please evaluate the following regarding the ambulance/equipment:

	Excellent	Good	Neutral	Fair	Poor	N/A
Cleanliness	Cleanliness Excellent	Cleanliness Good	Cleanliness Neutral	Cleanliness Fair	Cleanliness Poor	Cleanliness N/A
Felt Secure on Ambulance Stretcher	Felt Secure on Ambulance Stretcher Excellent	Felt Secure on Ambulance Stretcher Good	Felt Secure on Ambulance Stretcher Neutral	Felt Secure on Ambulance Stretcher Fair	Felt Secure on Ambulance Stretcher Poor	Felt Secure on Ambulance Stretcher N/A
Free of Odors	Free of Odors Excellent	Free of Odors Good	Free of Odors Neutral	Free of Odors Fair	Free of Odors Poor	Free of Odors N/A
Comfort of Ambulance Ride	Comfort of Ambulance Ride Excellent	Comfort of Ambulance Ride Good	Comfort of Ambulance Ride Neutral	Comfort of Ambulance Ride Fair	Comfort of Ambulance Ride Poor	Comfort of Ambulance Ride N/A

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* 7. Overall, how would you rate your experience with Good Fellowship?

Excellent

Very good

Good

Fair

Poor

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* 8. Is there anything we could have done to improve your experience?

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* 9. Do you remember the name(s) of the crew member(s)?

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* 10. Contact Information (Optional)

First Name

Last Name

Street Address

City

State

Zip Code

Phone Number

Email Address