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* 1. What was the location of your incident (city)?

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* 2. Name (optional)

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* 3. What is your age?

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* 4. What language do you mainly speak at home?

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* 5. What is the date of service requested? (optional)

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* 6. May we contact you with questions regarding your service?

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* 7. Please indicate whether you agree or disagree with the following statements:

  Strongly Agree Agree Somewhat Agree Disagree Strongly Disagree N/A
a) The Brevard County Fire Rescue team encouraged me to be transported to the hospital.
b) The Brevard County Fire Rescue team treated me with courtesy and respect.
c) The Brevard County Fire Rescue team showed concern for my safety and comfort during transport.
d) Brevard County Fire Rescue responded to my emergency in a prompt, timely fashion.
e) Based on my experience, I would recommend Brevard County Fire Rescue to my friends and family.

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* 8. Please read the following statements regarding your recent experience with Brevard County Fire Rescue. Click the answer that best describes your experience.

  Excellent Very Good Good Fair Poor N/A
a) Please rate your overall level of satisfaction with Brevard County Fire Rescue.
b) Please rate your opinion of the emergency medical care provided by Brevard County Fire Rescue.
c) Please rate the appearance of the Brevard County Fire Rescue team.

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* 9. If you could change any aspect of Brevard County Fire Rescue, what would you change?

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