Service Feedback Survey Question Title * 1. Patient's Name: (Required.) Question Title * 2. Name of individual completing the feedback form: (Required.) Question Title * 3. Date of ambulance service: (Required.) Date: Date Question Title * 4. Reason an ambulance was needed: Emergency (9-1-1 contacted for a medical emergency) Non Emergency (did not have an emergency but needed assistance) Other Question Title * 5. Did the ambulance arrive timely: Yes No No, but weather was bad Other (please specify) Question Title * 6. Were the Lancaster EMS employees professional (with care and appearance): (Required.) Very professional Unprofessional Somewhat professional Other (please specify) Question Title * 7. The Lancaster EMS employees were kind, caring, respectful and empathic: (Required.) Very Mostly Not at alll Other (please specify) Question Title * 8. Did the Lancaster EMS employees make reasonable efforts to ensure privacy / confidentiality: Yes No Unknown Not applicable Question Title * 9. Were procedures and any treatment explained: Yes No I do not remember Other (please specify) Question Title * 10. Was the patient able to be transported to the patient's preferred (local) hospital: Yes No The patient was not transported Other (please specify) Question Title * 11. Overall, the care and transportation I received from Lancaster EMS was: Excellent Good Fair Poor Other (please specify) Question Title * 12. Would you like someone to contact you: Yes - Include best way and time to make contact in comment box below No Other (please specify) Question Title * 13. Any additional comments or suggestions: Question Title * 14. May we share your responses with our team members and our medical director: Yes No Other (please specify) Done
