What was the Date and approximate time of your emergency? *

Incident Number *

How would you rate your overall level of satisfaction with us?
Highly SatisfiedSomewhat SatisfiedNeutralSomewhat DissatisfiedHighly Dissatisfied

Were you offered transport to the hospital in an ambulance?
YesNo

Did the personnel explain the risks of not being evaluated at a hospital to you and did you sign a refusal?
YesNo

After being treated by our personnel, were you hospitalized within the next 24 hours (not including the emergency department)?
YesNo

• EMS Dispatch and Assistance from 911 call ExcellentGoodFairPoor
• Response Time ExcellentGoodFairPoor
• Appearance and Cleanliness of Vehicle ExcellentGoodFairPoor
• Quality of Care Received ExcellentGoodFairPoor
• Patient Comfort provided by EMS Personnel ExcellentGoodFairPoor
• Courtesy and Respect from EMS Personnel ExcellentGoodFairPoor
• Explanation of Treatment ExcellentGoodFairPoor
• Regard for Family and Friends ExcellentGoodFairPoor
• Professionalism ExcellentGoodFairPoor
• Appearance of EMS Personnel ExcellentGoodFairPoor

How likely are you to share your experience with us with family, friends or coworkers?
Very LikelySomewhat LikelyNeutralSomewhat UnlikelyVery Unlikely

What is your gender?
Prefer not to answerMaleFemale

Which category describes your age?
Prefer not to answerYounger than 1818 - 2425 - 3435 - 4445 - 5455 - 6465 or older

What best describes your employment status?
Prefer not to answerEmployed full-timeEmployed part-timeSelf-employedNot employed but looking for workNot employed not looking for workRetiredStudentMilitaryHomemakerOther

Any additional comments or suggestions?