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.

Question Title

* 1. The person receiving the service today is:

male

female

0 - 17 years old

18 - 34 years old

35 - 49 years old

50 - 64 years old

65 - 74 years old

75 or older

Question Title

* 2. Date of Service:

Date

Question Title

* 3. Approximate time the ambulance arrived:

7 am - 3 pm

3 pm - 11 pm

11 pm - 7 am

Question Title

* 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:

Question Title

* 5. The EMS staff explained procedures they performed so that you could understand:

Question Title

* 6. How safe was the ambulance ride:

Question Title

* 7. How comfortable were you during the ambulance ride:

Question Title

* 8. The EMS staff asked and answered questions in a way you could understand:

Question Title

* 9. You were involved in your care decisions as much as possible under the circumstances:

Question Title

* 10. How well were your family members informed of your condition and care:

Question Title

* 11. Please rate our attention to these aspects of your care:

	1	2	3	4	5
Pain and discomfort relieved	Pain and discomfort relieved 1	Pain and discomfort relieved 2	Pain and discomfort relieved 3	Pain and discomfort relieved 4	Pain and discomfort relieved 5
Confidentiality of treatment	Confidentiality of treatment 1	Confidentiality of treatment 2	Confidentiality of treatment 3	Confidentiality of treatment 4	Confidentiality of treatment 5
Respect for physical privacy	Respect for physical privacy 1	Respect for physical privacy 2	Respect for physical privacy 3	Respect for physical privacy 4	Respect for physical privacy 5

Question Title

* 12. The professional manner and appearance of your EMS caregiver:

Question Title

* 13. The appearance and cleanliness of the ambulance interior:

Question Title

* 14. How did the staff do in these care areas:

	1	2	3	4	5
Support	Support 1	Support 2	Support 3	Support 4	Support 5
Respect	Respect 1	Respect 2	Respect 3	Respect 4	Respect 5
Friendliness	Friendliness 1	Friendliness 2	Friendliness 3	Friendliness 4	Friendliness 5

Question Title

* 15. Your satisfaction with your overall emergency care:

Question Title

* 16. Please rate your satisfaction with the 911 dispatching service:

	1	2	3	4	5
Call answered promptly	Call answered promptly 1	Call answered promptly 2	Call answered promptly 3	Call answered promptly 4	Call answered promptly 5
Familiar with location and incident	Familiar with location and incident 1	Familiar with location and incident 2	Familiar with location and incident 3	Familiar with location and incident 4	Familiar with location and incident 5
Courtesy of the dispatcher	Courtesy of the dispatcher 1	Courtesy of the dispatcher 2	Courtesy of the dispatcher 3	Courtesy of the dispatcher 4	Courtesy of the dispatcher 5

Question Title

* 17. Would you recommend our ambulance service to family and friends:

Yes, would definitely recommend

Might or might not recommend

No, would definitely not recommend

Question Title

* 18. Please tell us one thing we could do to improve our service:

Question Title

* 19. OPTIONAL INFORMATION

Name:

Address:

Telephone:

Question Title

* 1. The person receiving the service today is:

Question Title

* 2. Date of Service:

Question Title

* 3. Approximate time the ambulance arrived:

Question Title

* 4. Please use this scale for questions 4 - 16:1-Poor2-Fair3-Good4-Very Good5-OutstandingYour satisfaction with the time you waited for EMS personnel to arrive:

Question Title

* 5. The EMS staff explained procedures they performed so that you could understand:

Question Title

* 6. How safe was the ambulance ride:

Question Title

* 7. How comfortable were you during the ambulance ride:

Question Title

* 8. The EMS staff asked and answered questions in a way you could understand:

Question Title

* 9. You were involved in your care decisions as much as possible under the circumstances:

Question Title

* 10. How well were your family members informed of your condition and care:

Question Title

* 11. Please rate our attention to these aspects of your care:

Question Title

* 12. The professional manner and appearance of your EMS caregiver:

Question Title

* 13. The appearance and cleanliness of the ambulance interior:

Question Title

* 14. How did the staff do in these care areas:

Question Title

* 15. Your satisfaction with your overall emergency care:

Question Title

* 16. Please rate your satisfaction with the 911 dispatching service:

Question Title

* 17. Would you recommend our ambulance service to family and friends:

Question Title

* 18. Please tell us one thing we could do to improve our service:

Question Title

* 19. OPTIONAL INFORMATION

* 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: