KARNES COUNTY EMS

EMS Patient Satisfaction Survey

Karnes County EMS is conducting this confidential survey to evaluate our ambulance and paramedic service. Your feedback is important and valuable in helping us provide the best pre-hospital emergency care for you and your loved ones. The information you provide is confidential and will only be used internally by KCEMS administration. Thank you for your time.

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* 1. Please tell us the date of your emergency?

Date / Time

Date

Time

AM/PM

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* 2. Are you the patient?

YES

If not please state your relationship to the patient

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* 3. Please rate EMS crew on the following attributes.

	POOR	FAIR	GOOD	EXCELLENT
Professionalism	Professionalism POOR	Professionalism FAIR	Professionalism GOOD	Professionalism EXCELLENT
Friendly / Courteous	Friendly / Courteous POOR	Friendly / Courteous FAIR	Friendly / Courteous GOOD	Friendly / Courteous EXCELLENT
Concerned / Caring	Concerned / Caring POOR	Concerned / Caring FAIR	Concerned / Caring GOOD	Concerned / Caring EXCELLENT
Knowledgeable / Skilled	Knowledgeable / Skilled POOR	Knowledgeable / Skilled FAIR	Knowledgeable / Skilled GOOD	Knowledgeable / Skilled EXCELLENT

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* 4. Did our EMS crew listen to what you had to say?

YES

Additional Comments

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* 5. Did our EMS crew explain what they were doing?

YES

Additional Comments

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* 6. Did you feel confident in the care you received?

YES

Additional Comments

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* 7. Would you like for someone from Karnes County EMS to contact you in response to possible concerns you've mentioned in this survey?

YES

If yes please provide your name, number, or email address. (This information will only be used to contact you for follow up to this concern.)