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Customer Satisfaction Survey

Emergency Medical System Survey

We are committed to provide the highest levels of care to each of our patients. You can help us reach this goal by completing this survey and telling us what you think about our EMS services. All your answers are confidential. Thank you.
1.The person receiving the service today is:
2.Date of Service:
*
3.Approximate time the ambulance arrived:
4.Please use this scale for questions 4 - 16:

1-Poor

2-Fair

3-Good

4-Very Good

5-Outstanding


Your satisfaction with the time you waited for EMS personnel to arrive:
5.The EMS staff explained procedures they performed so that you could understand:
6.How safe was the ambulance ride:
7.How comfortable were you during the ambulance ride:
8.The EMS staff asked and answered questions in a way you could understand:
9.You were involved in your care decisions as much as possible under the circumstances:
10.How well were your family members informed of your condition and care:
11.Please rate our attention to these aspects of your care:
1
2
3
4
5
Pain and discomfort relieved
Confidentiality of treatment
Respect for physical privacy
12.The professional manner and appearance of your EMS caregiver:
13.The appearance and cleanliness of the ambulance interior:
14.How did the staff do in these care areas:
1
2
3
4
5
Support
Respect
Friendliness
15.Your satisfaction with your overall emergency care:
16.Please rate your satisfaction with the 911 dispatching service:
1
2
3
4
5
Call answered promptly
Familiar with location and incident
Courtesy of the dispatcher
17.Would you recommend our ambulance service to family and friends:
18.Please tell us one thing we could do to improve our service:
19.OPTIONAL INFORMATION