1. General Information

We want to thank you in advance for completing this questionaire. Your response will help us in improving our service to the citizens that we serve

Question Title

* 1. Date of Service


Question Title

* 2. Is Patient

Question Title

* 3. What is patient's age?

INSTRUCTIONS: Please rate the services you received while using our ambulance service. Click on the dot that best describes your experience. If a question does not apply to you or is unknown, please mark N/A. Space is provided for you to comment on positive or negative experiences that may have happened to you.

Question Title

* 4. The person you called for service ( 911 Center Dispatcher)

  Very Poor Poor Fair Good Very Good N/A
Helpfulness of the 911 Dispatcher you called for ambulance service
Concern shown by the Dispatcher
Extent to which you were told what to do until the ambulance arrived

Question Title

* 5. The Ambulance

  Very Poor Poor Fair Good Very Good N/A
Extent to which the ambulance arrived in a timely manner
Cleanliness of the ambulance
Comfort of the ride
Skill of the person driving the ambulance