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* 1. Please indicate the month service was provided:

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* 2. Please indicate the day service was provided:

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* 3. Please indicate the year service was provided:

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* 4. Please indicate the day of the week service was provided:

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* 5. Please indicate the approximate time service was provided:

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* 6. Customer Service for the 911 Center (Telecommunicator):

  Very Poor Poor Fair Good Very Good N/A
The (911) Telecommunicator's ability to provide helpful information:
Level of courtesy of (911) Telecommunicator:
The (911) Telecommunicator's ability to treat caller with respect and dignity:

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* 7. Customer Service for the EMS System:

  Very Poor Poor Fair Good Very Good N/A
Uniform Appearance:
Cleanliness of Ambulance and Equipment:
Paramedic / EMT ability to treat family / friends with respect and dignity:
Courtesy of Paramedics/ EMTs to patient:
Paramedic's / EMT's concern about keeping you informed:
Technical skill of Paramedics / EMTs:
Overall Customer Service Satisfaction with E-911 and EMS:

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* 8. Comments:

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* 9. Please indicate the staff the service was provided by (if known):

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