Cardiac Incident Survey

Question Title

1. Where were you when the incident occurred? (Required.)

On scene

At station

On the way home

At home

Other (please specify)

Question Title

2. Did you experience any of these symptoms (Select all that apply)? (Required.)

Chest pain

Arms feeling heavy

Shortness of breath

Coughing

Nausea

Vomiting

Dizziness

Face grey/pale in color

Feeling clammy and sweaty

Other (please specify)

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3. How long after onset did you wait before you or someone took action to get you help? (Required.)

1 hour

1 day

1 week

Clear

i We adjusted the number you entered based on the slider’s scale.

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4. Who took you to the hospital? (Required.)

Supervisor

Fellow firefighter

Friend or Family member

Took myself

EMS

Other (please specify)

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5. What was the outcome of the event? (Required.)

Returned to work (full duty)

Returned to work (limited duty)

Went on disability

Retired

Other (please specify)

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6. Type of firefighter (Required.)

Volunteer

Career

Paid on-call

Volunteer on-call

EMS responder

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7. What is your age? (Required.)

<25

26-35

36-45

46-55

56-65

66+

Question Title

8. We'd appreciate your contact information so we may follow up with you.

Name

Department

City/Town

State/Province

Email Address

Phone Number

Cardiac Incident Survey

Question Title

* 1. Where were you when the incident occurred? (Required.)

Question Title

* 2. Did you experience any of these symptoms (Select all that apply)? (Required.)

Question Title

* 3. How long after onset did you wait before you or someone took action to get you help? (Required.)

Question Title

* 4. Who took you to the hospital? (Required.)

Question Title

* 5. What was the outcome of the event? (Required.)

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* 6. Type of firefighter (Required.)

Question Title

* 7. What is your age? (Required.)

Question Title

* 8. We'd appreciate your contact information so we may follow up with you.

1. Where were you when the incident occurred? (Required.)

2. Did you experience any of these symptoms (Select all that apply)? (Required.)

3. How long after onset did you wait before you or someone took action to get you help? (Required.)

4. Who took you to the hospital? (Required.)

5. What was the outcome of the event? (Required.)

6. Type of firefighter (Required.)

7. What is your age? (Required.)

8. We'd appreciate your contact information so we may follow up with you.