Person Completing the Survey Details

1. First Name (Optional)

2.   Surname (Optional)

3. Relationship to patient:

The Patient's Details

4. Patient Gender

5. Patient Age Group

6. Is the patient of Aboriginal, Torres Strait Islander origin or both?

7. What is the patient’s country of birth?

8. Which language does the patient primarily speak at home?

9. If the patient needed an interpreter, were they given access to one?

10. Does the patient have Ambulance Cover for emergency attendance and/or transport?

Service Details

11. Date of service (if known)

12. Who called the ambulance?

13. Where was the patient when they needed an ambulance?

14. What was the reason to call for an ambulance?

The Triple Zero (000) Call

15. Were you the person who called triple zero?

16. Do you feel that the SAAS emergency call taker listened to the person who made the call?

17. Was the caller confident that the SAAS emergency call taker understood what the emergency was?

18. If the patient waited longer than 60 minutes for an ambulance, was a follow up call from SAAS received?

Ambulance Arrival

19. Was the patient satisfied that the ambulance arrived within a reasonable timeframe?

20. Did the ambulance crew introduce themselves to the patient when they arrived?

21. Did the ambulance crew accurately identify the patient?

22. Was the ambulance vehicle and equipment clean and tidy?

Clinical Assessment
Involvement in care and treatment

23. Did the ambulance crew explain things in a way the patient could understand?

24. Did the ambulance crew ask about the patient’s current medication?

25. Did the ambulance crew ask about the patient’s past medical history?

26. Was the patient involved as much as they wanted to be in decisions about their treatment?

27. Do you feel that the ambulance crew listened to the patient?

28. Do you feel the ambulance crew treated the patient with respect and dignity?

29. Did the ambulance crew involve the patient/family/guardian/carer in the discussions?

30. Was the patient/family/guardian/carer provided adequate information in relation to their condition?

31. Did the ambulance crew appropriately manage any concerns raised about the patient’s condition?

Was the patient treated for any of the following?

32. Pain?

33. Did the ambulance crew do everything they could to manage your pain?

34. Heart Attack?

35. Stroke?

36. Physical Injury?

Referral

37. Was the patient transported to a hospital by SAAS?

38. Was the patient involved as much as they wanted to be in decisions about going to hospital or staying at home?

39. If the patient was transported to a hospital by SAAS, did the ambulance crew involve the patient/family/your carer/ guardian in the handover to the medical staff?

40. If SAAS did not take the patient to hospital, was the patient/family/carer/guardian provided with written documentation about ongoing care?

41. Did you feel the ambulance crew work well together to plan and coordinate the patient’s treatment/transport?

42. Did the patient have any worries or fears when in the care of the ambulance crew that were not addressed?

43. If yes, what were they?

Consumer Satisfaction

44. Overall, was the patient satisfied with the service they received?

45. If you were not the patient, were you satisfied with the service provided to the patient?

46. Would you recommend SA Ambulance Service to a relative or friend?

47. Would you like information about SA Ambulance Service membership sent to you?

48. Send to:

Additional Comments/Feedback

49. In general, would you say the patient’s health is?

50. Would you like the SA Ambulance Service, Consumer Adviser to contact you about a specific issue?

51. Address

52. Please attach or email a brief description of the issue to the address below.

Thank you for taking the time to complete this survey. Your comments will help us to learn and improve our service to the community

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