Williamson County EMS Patient Satisfaction Survey

We want to thank you in advance for taking this survey.

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* 1. Date of Call

Date

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* 2. Call Number (Optional)

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* 3. What is the patient's age?

Under 18

18 - 30

31 - 44

45 - 54

55 - 64

65 or older

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* 4. Is patient?

Male

Female

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* 5. This survey is completed by:

Patient

Spouse

Other Family

Other Caregiver

Instructions: Please rate the services you received while using out ambulance service. Select the circle that best describes your experience. If a question does not apply to you or is unknown, please skip to the next question. Space is provided for you to comment on positive or negative experiences that may have happened to you.

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* 6. The person you called for service (dispatcher)

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

Comments

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* 7. First Responders - If medical first responders arrived before the ambulance to assist you, please answer the following. If no first responders, please go to the next section.

	Very Poor	Poor	Fair	Good	Very Good
Extent to which the first responders arrived in a timely manner	Extent to which the first responders arrived in a timely manner Very Poor	Extent to which the first responders arrived in a timely manner Poor	Extent to which the first responders arrived in a timely manner Fair	Extent to which the first responders arrived in a timely manner Good	Extent to which the first responders arrived in a timely manner Very Good
Care shown by the first responders	Care shown by the first responders Very Poor	Care shown by the first responders Poor	Care shown by the first responders Fair	Care shown by the first responders Good	Care shown by the first responders Very Good
Professionalism of first responders	Professionalism of first responders Very Poor	Professionalism of first responders Poor	Professionalism of first responders Fair	Professionalism of first responders Good	Professionalism of first responders Very Good

Comments

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* 8. The Ambulance

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

Comments

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* 9. Paramedics

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

Comments

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* 10. Office Staff

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

Comments

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* 11. Overall Assessment

	Very Poor	Poor	Fair	Good	Very Good
How well did our staff work together to care for you	How well did our staff work together to care for you Very Poor	How well did our staff work together to care for you Poor	How well did our staff work together to care for you Fair	How well did our staff work together to care for you Good	How well did our staff work together to care for you Very Good
Extent to which the services received were worth the fees charged	Extent to which the services received were worth the fees charged Very Poor	Extent to which the services received were worth the fees charged Poor	Extent to which the services received were worth the fees charged Fair	Extent to which the services received were worth the fees charged Good	Extent to which the services received were worth the fees charged Very Good
Overall rating of the care provided by Williamson County EMS	Overall rating of the care provided by Williamson County EMS Very Poor	Overall rating of the care provided by Williamson County EMS Poor	Overall rating of the care provided by Williamson County EMS Fair	Overall rating of the care provided by Williamson County EMS Good	Overall rating of the care provided by Williamson County EMS Very Good

Comments

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* 12. How likely is it that you would recommend Williamson County EMS to a friend or colleague?

Not at all likely

Extremely likely

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* 13. What could we do better the next time?

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* 14. If you would like to discuss any problems, please enter your name and day time telephone number below.

Name

Phone Number

Williamson County EMS
PO Box 873, Georgetown, TX 78627
(512) 943-1264