Customer Satisfaction Survey Template

Patient Care Satisfaction

Please take about 2 minutes to complete this survey! Your responses are not track but are used to identify how we providing care and where it can be improved! Please fill out every field and submit the survey. Thank you very much!

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* 1. What is your Run Number?

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* 2. How likely is it that you would recommend Warren-Wentworth Ambulance Service to a friend or colleague?

NOT AT ALL LIKELY

EXTREMELY LIKELY

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* 3. Please rate the EMS personnel on the following topics

	Not Satisfactory	Somewhat Satisfactory	Mildly Satisfactory	Satisfactory	Very Satisfactory
Competency	Competency Not Satisfactory	Competency Somewhat Satisfactory	Competency Mildly Satisfactory	Competency Satisfactory	Competency Very Satisfactory
Professionalism	Professionalism Not Satisfactory	Professionalism Somewhat Satisfactory	Professionalism Mildly Satisfactory	Professionalism Satisfactory	Professionalism Very Satisfactory
Compasion for you and your family	Compasion for you and your family Not Satisfactory	Compasion for you and your family Somewhat Satisfactory	Compasion for you and your family Mildly Satisfactory	Compasion for you and your family Satisfactory	Compasion for you and your family Very Satisfactory
Efficiency	Efficiency Not Satisfactory	Efficiency Somewhat Satisfactory	Efficiency Mildly Satisfactory	Efficiency Satisfactory	Efficiency Very Satisfactory
Atentive Listener	Atentive Listener Not Satisfactory	Atentive Listener Somewhat Satisfactory	Atentive Listener Mildly Satisfactory	Atentive Listener Satisfactory	Atentive Listener Very Satisfactory
Perceived Knowledge	Perceived Knowledge Not Satisfactory	Perceived Knowledge Somewhat Satisfactory	Perceived Knowledge Mildly Satisfactory	Perceived Knowledge Satisfactory	Perceived Knowledge Very Satisfactory
Communicated Effectively	Communicated Effectively Not Satisfactory	Communicated Effectively Somewhat Satisfactory	Communicated Effectively Mildly Satisfactory	Communicated Effectively Satisfactory	Communicated Effectively Very Satisfactory

Other (please specify)

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* 4. Cleanliness of Ambulance/equipment

Not Satisfactory

Somewhat Satisfactory

Mildly Satisfactory

Satisfactory

Very Satisfactory

Other (please specify)

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* 5. Did you receive a copy of our privacy notice?

Yes

I refused privacy notice pamphlet

I am not sure

Other (please specify)

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* 6. How would you rate our response time?

Not Satisfactory

Somewhat Satisfactory

Mildly Satisfactory

Satisfactory

Very Satisfactory

N/a

Other (please specify)

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* 7. Overall satisfaction with Warren-Wentworth Ambulance Service

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

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* 9. If any members of our staff were especially helpful, please let us know who they are. We would like to show them our appreciation.

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* 10. Would you like to be contacted by Warren-Wentworth Ambulance Service regarding this survey?

Yes