Leon County EMS Pre-Hospital Patient Satisfaction Survey

We want to hear from our patients. Please let us know how your experience was when using Leon County EMS services.

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* 1. Enter today's date:

Date

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* 2. Date patient used Leon County EMS services.

Date

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* 3. What is your relation to the patient that used our services?

I am the patient

Parent/ caregiver

Spouse

Significant other

Son/ daughter

Sibling

Friend

Other

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* 4. Patient's age:

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* 5. Patient's gender

Male

Female

Rather not specify

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* 6. Please rate your most recent experience:

	Excellent	Good	Satisfactory	Poor	Unacceptable	N/A
Response time of EMS team	Response time of EMS team Excellent	Response time of EMS team Good	Response time of EMS team Satisfactory	Response time of EMS team Poor	Response time of EMS team Unacceptable	Response time of EMS team N/A
Professionalism of the EMS team	Professionalism of the EMS team Excellent	Professionalism of the EMS team Good	Professionalism of the EMS team Satisfactory	Professionalism of the EMS team Poor	Professionalism of the EMS team Unacceptable	Professionalism of the EMS team N/A
Friendliness of team members	Friendliness of team members Excellent	Friendliness of team members Good	Friendliness of team members Satisfactory	Friendliness of team members Poor	Friendliness of team members Unacceptable	Friendliness of team members N/A
Appearance of team members	Appearance of team members Excellent	Appearance of team members Good	Appearance of team members Satisfactory	Appearance of team members Poor	Appearance of team members Unacceptable	Appearance of team members N/A
Cleanliness of vehicle / equipment	Cleanliness of vehicle / equipment Excellent	Cleanliness of vehicle / equipment Good	Cleanliness of vehicle / equipment Satisfactory	Cleanliness of vehicle / equipment Poor	Cleanliness of vehicle / equipment Unacceptable	Cleanliness of vehicle / equipment N/A
Degree ambulance staff took your condition seriously	Degree ambulance staff took your condition seriously Excellent	Degree ambulance staff took your condition seriously Good	Degree ambulance staff took your condition seriously Satisfactory	Degree ambulance staff took your condition seriously Poor	Degree ambulance staff took your condition seriously Unacceptable	Degree ambulance staff took your condition seriously N/A
Overall quality of service	Overall quality of service Excellent	Overall quality of service Good	Overall quality of service Satisfactory	Overall quality of service Poor	Overall quality of service Unacceptable	Overall quality of service N/A

Comments:

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* 7. Please rate your most recent experience (cont.):

	Excellent	Good	Satisfactory	Poor	Unacceptable	N/A
Ambulance staff's concern for your privacy	Ambulance staff's concern for your privacy Excellent	Ambulance staff's concern for your privacy Good	Ambulance staff's concern for your privacy Satisfactory	Ambulance staff's concern for your privacy Poor	Ambulance staff's concern for your privacy Unacceptable	Ambulance staff's concern for your privacy N/A
Ambulance staff's efforts to inform you about treatment	Ambulance staff's efforts to inform you about treatment Excellent	Ambulance staff's efforts to inform you about treatment Good	Ambulance staff's efforts to inform you about treatment Satisfactory	Ambulance staff's efforts to inform you about treatment Poor	Ambulance staff's efforts to inform you about treatment Unacceptable	Ambulance staff's efforts to inform you about treatment N/A
Degree to which the ambulance staff worked together to care for you	Degree to which the ambulance staff worked together to care for you Excellent	Degree to which the ambulance staff worked together to care for you Good	Degree to which the ambulance staff worked together to care for you Satisfactory	Degree to which the ambulance staff worked together to care for you Poor	Degree to which the ambulance staff worked together to care for you Unacceptable	Degree to which the ambulance staff worked together to care for you N/A
Your confidence in skill of ambulance staff	Your confidence in skill of ambulance staff Excellent	Your confidence in skill of ambulance staff Good	Your confidence in skill of ambulance staff Satisfactory	Your confidence in skill of ambulance staff Poor	Your confidence in skill of ambulance staff Unacceptable	Your confidence in skill of ambulance staff N/A
Ambulance staff cared for you as a person	Ambulance staff cared for you as a person Excellent	Ambulance staff cared for you as a person Good	Ambulance staff cared for you as a person Satisfactory	Ambulance staff cared for you as a person Poor	Ambulance staff cared for you as a person Unacceptable	Ambulance staff cared for you as a person N/A
How well was your pain controlled	How well was your pain controlled Excellent	How well was your pain controlled Good	How well was your pain controlled Satisfactory	How well was your pain controlled Poor	How well was your pain controlled Unacceptable	How well was your pain controlled N/A
Your comfort when moved by ambulance staff	Your comfort when moved by ambulance staff Excellent	Your comfort when moved by ambulance staff Good	Your comfort when moved by ambulance staff Satisfactory	Your comfort when moved by ambulance staff Poor	Your comfort when moved by ambulance staff Unacceptable	Your comfort when moved by ambulance staff N/A
Comfort of ambulance ride	Comfort of ambulance ride Excellent	Comfort of ambulance ride Good	Comfort of ambulance ride Satisfactory	Comfort of ambulance ride Poor	Comfort of ambulance ride Unacceptable	Comfort of ambulance ride N/A

Leon County EMS Pre-Hospital Patient Satisfaction Survey

Question Title

* 1. Enter today's date:

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* 2. Date patient used Leon County EMS services.

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* 3. What is your relation to the patient that used our services?

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* 4. Patient's age:

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* 5. Patient's gender

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* 6. Please rate your most recent experience:

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* 7. Please rate your most recent experience (cont.):

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* 8. Do you have any other comments, questions, or concerns?

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* 9. Would you like to be contacted regarding the services provided to you?