NCHD EMS Feedback Survey Question Title * 1. Date of Service Date / Time Date Question Title * 2. PERSON COMPLETING SURVEY Patient Spouse Parent Other Family Other Caregiver Friend Question Title * 3. PLEASE RATE THE TIMELINESS OF THE AMBULANCE RESPONSE POOR FAIR GOOD EXCELLENT POOR FAIR GOOD EXCELLENT Question Title * 4. PLEASE RATE THE PROFESSIONALISM AND APPEARANCE OF NCHD RESPONDERS POOR FAIR GOOD EXCELLENT POOR FAIR GOOD EXCELLENT Question Title * 5. PLEASE RATE THE QUALITY OF CARE PROVIDED POOR FAIR GOOD EXCELLENT POOR FAIR GOOD EXCELLENT Question Title * 6. PLEASE RATE THE CLEANLINESS OF THE NCHD AMBULANCE POOR FAIR GOOD EXCELLENT POOR FAIR GOOD EXCELLENT Question Title * 7. THE NCHD RESPONDERS KEPT ME AND/OR THE PATIENT INFORMED ABOUT TREATMENT Strongly Disagree Disagree Neutral Agree Strongly agree Strongly Disagree Disagree Neutral Agree Strongly agree Question Title * 8. NCHD RESPONDERS RESPECTED AND MAINTAINED MY PRIVACY Strongly Disagree Disagree Neutral Agree Strongly Agree Strongly Disagree Disagree Neutral Agree Strongly Agree Question Title * 9. PLEASE PROVIDE YOUR INFORMATION IF YOU WOULD LIKE US TO CONTACT YOU Name Email Address Phone Number Question Title * 10. ANY ADDITIONAL FEEDBACK Done