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* 1. Date of Service

Date / Time

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* 2. Patients age?

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* 3. Patients Gender?

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* 4. Person Completing this Survey

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* 5. The Person you called for Service (911 Dispatcher)

  Very Poor Poor Fair Good Very Good N/A
Helpfulness of the Person you called for ambulance service
Concern shown by the person you called for ambulance service
Extent to which you were told what to do until the ambulance arrived

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* 6. The Ambulance

  Very Poor Poor Fair Good Very Good
Extent to which the ambulance arrived in a timely manner
Cleanliness of the ambulance
Comfort of the ride

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* 7. Medics

  Very Poor Poor Fair Good Very Good N/A
Care shown by the medics who arrived with the ambulance
Degree to which the medics listened to you and/or your family
Skill of the medics
Extent to which the medics kept you informed about your treatment
Extent to which medics included you in the treatment decisions (if applicable)
Degree to which the medics relieved your pain or discomfort
Medics' concern for your privacy
Extent to which medics cared for you as a person
Professionalism of the medics

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* 8. Office Staff

  Very Poor Poor Fair Good Very Good N/A
Professionalism of the staff in our billing office
Willingness of the staff in our billing office to address your needs

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* 9. Overall Assessment

  Very poor Poor Fair Good Very Good
How well did our staff work together to care for you
Extent to which the services received were up to your expectations
Overall rating of the care provided by our Emergency Medical Transportation service

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* 10. What could we do better the next time? Or if you would like to discuss any problems, please type your name and daytime telephone number, with area code, below.

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